MEDICARE: PRINCE GEORGE'S AMBULATORY CARE CENTER/ENDOSCOPY SUITES, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QE0800X	Endoscopy Clinic/Center	A1036	MD

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	RC3	OTHER	DC	CAREFIRST BCBS

General Provider Information

NPI Number	:	1457352361
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PRINCE GEORGE'S AMBULATORY CARE CENTER/ENDOSCOPY SUITES, INC.

Provider Business Mailing Address
First Line	:	6001 LANDOVER RD
Second Line	:	SUITE 1
City	:	CHEVERLY
State	:	MD
Zip	:	20785-1143
Country	:	US
Telephone Number	:	301-773-3900
Fax Number	:	301-773-7869

Provider Business Practice Location Address
First Line	:	6001 LANDOVER RD
Second Line	:	SUITE 1
City	:	CHEVERLY
State	:	MD
Zip	:	20785-1143
Country	:	US
Telephone Number	:	301-773-3900
Fax Number	:	301-773-7869

Authorized Official
Title or Position	:	DIRECTOR
Name	:	VENKATARAMAN PREM CHANDAR
Credential	:	M. D.
Telephone Number	:	301-773-3900

Provider Enumeration Date	:	08/02/2005
Last Update Date	:	08/22/2020

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