Basic Information
| Provider Information | |||||||||
| NPI: | 1114025608 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ELLICOTT CITY AMBULATORY SURGERY CENTER, LLLP | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| OtherOrganizationName: | ELLICOTT CITY AMBULATORY SURGERY CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2850 NORTH RIDGE ROAD | ||||||||
| Address2: | |||||||||
| City: | ELLICOTT CITY | ||||||||
| State: | MD | ||||||||
| PostalCode: | 21043 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4104611600 | ||||||||
| FaxNumber: | 4107507615 | ||||||||
| Practice Location | |||||||||
| Address1: | 2850 NORTH RIDGE ROAD | ||||||||
| Address2: | |||||||||
| City: | ELLICOTT CITY | ||||||||
| State: | MD | ||||||||
| PostalCode: | 21043 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4104611600 | ||||||||
| FaxNumber: | 4107507615 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/20/2006 | ||||||||
| LastUpdateDate: | 06/11/2010 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | HARTLEY | ||||||||
| AuthorizedOfficialFirstName: | MAUREEN | ||||||||
| AuthorizedOfficialMiddleName: | G | ||||||||
| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 4104611600 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | RN | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QA1903X | A1003R | MD | Y | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Surgical |
ID Information
| ID | Type | State | Issuer | Description | 410706300 | 05 | MD | MEDICAID |