Basic Information
| Provider Information | |||||||||
| NPI: | 1003002163 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CHARLES COUNTY SURGICAL ASSOCIATES, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4225 ALTAMONT PL UNIT 3 | ||||||||
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| City: | WHITE PLAINS | ||||||||
| State: | MD | ||||||||
| PostalCode: | 206953063 | ||||||||
| CountryCode: | US | ||||||||
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| Address1: | 4225 ALTAMONT PL UNIT 3 | ||||||||
| Address2: | |||||||||
| City: | WHITE PLAINS | ||||||||
| State: | MD | ||||||||
| PostalCode: | 206953063 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3013749591 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/21/2007 | ||||||||
| LastUpdateDate: | 09/21/2007 | ||||||||
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| AuthorizedOfficialLastName: | BERGER | ||||||||
| AuthorizedOfficialFirstName: | ROBERT | ||||||||
| AuthorizedOfficialMiddleName: | S | ||||||||
| AuthorizedOfficialTitleorPosition: | MD | ||||||||
| AuthorizedOfficialTelephone: | 3013749591 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ND0101X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Dermatology | MOHS-Micrographic Surgery |
No ID Information.