Basic Information
| Provider Information | |||||||||
| NPI: | 1447254172 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SURGICENTER OF BALTIMORE LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| OtherOrganizationName: | SURGICENTER OF BALTIMORE | ||||||||
| OtherOrganizationType: | 5 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 23 CROSSROADS DR | ||||||||
| Address2: | STE 100 | ||||||||
| City: | OWINGS MILLS | ||||||||
| State: | MD | ||||||||
| PostalCode: | 211175420 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4103560300 | ||||||||
| FaxNumber: | 4103567507 | ||||||||
| Practice Location | |||||||||
| Address1: | 23 CROSSROADS DRIVE | ||||||||
| Address2: | STE 100 | ||||||||
| City: | OWINGS MILLS | ||||||||
| State: | MD | ||||||||
| PostalCode: | 211175476 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4103560300 | ||||||||
| FaxNumber: | 4103567507 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/10/2005 | ||||||||
| LastUpdateDate: | 09/06/2016 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | LAMBIE | ||||||||
| AuthorizedOfficialFirstName: | ROSEMARY | ||||||||
| AuthorizedOfficialMiddleName: | L. | ||||||||
| AuthorizedOfficialTitleorPosition: | DELEGATED OFFICIAL | ||||||||
| AuthorizedOfficialTelephone: | 4103562409 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | RN | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QA1903X | A1045 | MD | Y | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Surgical |
ID Information
| ID | Type | State | Issuer | Description | NE3 | 01 | MD | CAREFIRST BCBS | OTHER | 242321900 | 05 | MD | MEDICAID | 25872 | 01 | MD | MAMSI | OTHER | 490001255 | 01 | MD | MEDICARE RAILROAD | OTHER | 02LM | 01 | MD | BCBS | OTHER | 110694 | 01 | MD | KAISER | OTHER | 0181741 | 01 | MD | AETNA | OTHER | 2614116 | 01 | MD | AETNA | OTHER | 6800095 | 01 | MD | UNITED HEALTHCARE | OTHER | 20103019SA | 01 | MD | CIGNA | OTHER | 055335 | 01 | MD | JOHNS HOPKINS | OTHER |