=====================================================
General NPI Number Information
=====================================================
NPI Number | 1780618801
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PINEY ORCHARD SURGERY CENTER, LLC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/11/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1132 ANNAPOLIS RD
-----------------------------------------------------
City | ODENTON
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21113-1647
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 410-674-0020
-----------------------------------------------------
Fax | 410-674-6226
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 631688
-----------------------------------------------------
City | BALTIMORE
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21263-1688
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 814-689-2066
-----------------------------------------------------
Fax | 814-689-2001
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PARTNER
-----------------------------------------------------
Name | DR. DOUGLAS ROBERT COLKITT
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 941-346-0858
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QA1903X
-----------------------------------------------------
Taxonomy Name | Ambulatory Surgical Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------