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General NPI Number Information
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NPI Number | 1912993700
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Entity Type | Organization
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Legal Business Name | PEMBROOKE SQUARE SURGERY CENTER, LLC
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Dates
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Enumeration Date | 09/27/2005
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Last Update Date | 11/18/2009
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Provider Practice Location Address
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Address Line | 11370 PEMBROOKE SQ
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City | WALDORF
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State | MD
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Zip | 20603-4842
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Country | US
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Telephone | 301-396-8492
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Fax | 301-396-8498
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Provider Business Mailing Address
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Address Line | 11370 PEMBROOKE SQ
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City | WALDORF
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State | MD
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Zip | 20603-4842
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Country | US
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Telephone | 301-396-8492
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Fax | 301-396-8498
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Authorized Official
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Title or Position | BUSINESS OFFICE MANAGER
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Name | MRS. LISA F CONLEY
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Credential | CPC-H
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Telephone | 301-396-8492
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QA1903X
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Taxonomy Name | Ambulatory Surgical Clinic/Center
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License Number | A1407
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License Number State | MD
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