Basic Information
| Provider Information | |||||||||
| NPI: | 1104161082 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MASSACHUSETTS AVENUE SURGICAL CONSULTANTS LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6400 GOLDSBORO RD STE 400 | ||||||||
| Address2: | |||||||||
| City: | BETHESDA | ||||||||
| State: | MD | ||||||||
| PostalCode: | 208175846 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3012630800 | ||||||||
| FaxNumber: | 3012630820 | ||||||||
| Practice Location | |||||||||
| Address1: | 6400 GOLDSBORO RD STE 400 | ||||||||
| Address2: | |||||||||
| City: | BETHESDA | ||||||||
| State: | MD | ||||||||
| PostalCode: | 208175846 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3012630800 | ||||||||
| FaxNumber: | 3012630820 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/04/2012 | ||||||||
| LastUpdateDate: | 12/04/2012 | ||||||||
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| AuthorizedOfficialLastName: | GROSS | ||||||||
| AuthorizedOfficialFirstName: | RANDALL | ||||||||
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| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 3012630800 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | MASSACHUSETTS AVENUE CONSULTING SERVICES LLC | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 246ZS0410X | Y | 193400000X SINGLE SPECIALTY GROUP |
No ID Information.