MEDICARE: EAGLE EYE SURGERY CENTER LLC

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	261QA1903X	Ambulatory Surgical Clinic/Center

General Provider Information

NPI Number	:	1669912788
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EAGLE EYE SURGERY CENTER LLC

Provider Business Mailing Address
First Line	:	15020 SHADY GROVE RD
Second Line	:	SUITE 302
City	:	ROCKVILLE
State	:	MD
Zip	:	20850-3364
Country	:	US
Telephone Number	:	301-279-9123
Fax Number	:	301-279-6828

Provider Business Practice Location Address
First Line	:	15001 DUFIEF MILL RD
Second Line	:
City	:	NORTH POTOMAC
State	:	MD
Zip	:	20878-2599
Country	:	US
Telephone Number	:	301-279-9123
Fax Number	:	301-279-6828

Authorized Official
Title or Position	:	OWNER
Name	:	TOUFIC S MELKI
Credential	:	M.D.
Telephone Number	:	301-279-9123

Provider Enumeration Date	:	03/08/2017
Last Update Date	:	03/20/2017

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