=====================================================
General NPI Number Information
=====================================================
NPI Number | 1790062636
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BAY SURGERY CENTERS - WALDORF, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/07/2011
-----------------------------------------------------
Last Update Date | 02/18/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2960 TECHNOLOGY PL STE 103A
-----------------------------------------------------
City | WALDORF
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 20601-4968
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 410-571-2946
-----------------------------------------------------
Fax | 410-571-2947
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 201 DEFENSE HWY STE 205
-----------------------------------------------------
City | ANNAPOLIS
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21401-7096
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 443-837-9914
-----------------------------------------------------
Fax | 410-571-2947
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | MR. DAMEAN FREAS
-----------------------------------------------------
Credential | DO
-----------------------------------------------------
Telephone | 410-571-2946
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QA1903X
-----------------------------------------------------
Taxonomy Name | Ambulatory Surgical Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------