Basic Information
| Provider Information | |||||||||
| NPI: | 1215967351 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | FRIENDSHIP AMBULATORY SURGERY CENTER | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | FRIENDSHIP AMBULATORY SURGERY CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 5550 FRIENDSHIP BLVD STE 270 | ||||||||
| Address2: | |||||||||
| City: | CHEVY CHASE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 208157297 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3012157347 | ||||||||
| FaxNumber: | 3017157345 | ||||||||
| Practice Location | |||||||||
| Address1: | 5550 FRIENDSHIP BLVD STE 270 | ||||||||
| Address2: | |||||||||
| City: | CHEVY CHASE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 208157297 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3012157347 | ||||||||
| FaxNumber: | 3017157345 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/04/2006 | ||||||||
| LastUpdateDate: | 02/12/2009 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | CRADDOCK | ||||||||
| AuthorizedOfficialFirstName: | MARY | ||||||||
| AuthorizedOfficialMiddleName: | K | ||||||||
| AuthorizedOfficialTitleorPosition: | MEDICAL DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 3012157347 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QA1903X | A1131 | MD | Y | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Surgical |
ID Information
| ID | Type | State | Issuer | Description | 68-00013 | 01 | EVERCARE | OTHER | 325991900 | 05 | MD | MEDICAID | 225660 | 01 | ALLIANCE | OTHER | 1490 | 01 | DC | BC/BS OF DC | OTHER | 225660 | 01 | MD | MAMSI | OTHER | ZZ13FR | 01 | MD | BC/BS NASCO ACCTS. | OTHER | 1143770001 | 01 | PALMETTO GOVT. TRICARE | OTHER | 1490 | 01 | CAREFIRST BLUE CHOICE | OTHER | ZZ13FR | 01 | MD | MARYLAND BC/BS | OTHER | 225660 | 01 | MD | MDIPA, ALL MAMSI | OTHER | 490002518 | 01 | RAILROAD MEDICARE | OTHER | ZZ13FR | 01 | MD | BC/BS NATIONAL ACCTS. | OTHER |