Basic Information
| Provider Information | |||||||||
| NPI: | 1669426706 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ADVANCED SURGERY CENTER,LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | ADVANCED SURGERY CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10110 MOLECULAR DRIVE | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | ROCKVILLE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 20850 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3018380437 | ||||||||
| FaxNumber: | 3018380439 | ||||||||
| Practice Location | |||||||||
| Address1: | 10110 MOLECULAR DRIVE | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | ROCKVILLE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 20850 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3018380437 | ||||||||
| FaxNumber: | 3018380439 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/22/2006 | ||||||||
| LastUpdateDate: | 08/19/2015 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | LACAVA | ||||||||
| AuthorizedOfficialFirstName: | ROBERT | ||||||||
| AuthorizedOfficialMiddleName: | CLAY | ||||||||
| AuthorizedOfficialTitleorPosition: | CLINICAL ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 3018380437 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | ADVANCED SURGERY CENTER, LLC | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QE0800X | A1400 | MD | Y | Ambulatory Health Care Facilities | Clinic/Center | Endoscopy |
ID Information
| ID | Type | State | Issuer | Description | 405873900 | 05 | MD | MEDICAID |