Basic Information
Provider Information | |||||||||
NPI: | 1942458062 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | ASC DEVELOPMENT COMPANY, LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1150 PROFESIONAL COURT | ||||||||
Address2: | SUITE P | ||||||||
City: | HAGERSTOWN | ||||||||
State: | MD | ||||||||
PostalCode: | 217404100 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3016659696 | ||||||||
FaxNumber: | 2404205715 | ||||||||
Practice Location | |||||||||
Address1: | 1150 PROFESIONAL COURT | ||||||||
Address2: | SUITE P | ||||||||
City: | HAGERSTOWN | ||||||||
State: | MD | ||||||||
PostalCode: | 217404100 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3016659696 | ||||||||
FaxNumber: | 2404205715 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/03/2008 | ||||||||
LastUpdateDate: | 03/09/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | PATEL | ||||||||
AuthorizedOfficialFirstName: | ANISH | ||||||||
AuthorizedOfficialMiddleName: | SHARAD | ||||||||
AuthorizedOfficialTitleorPosition: | REGIONAL MEDICAL DIRECTOR | ||||||||
AuthorizedOfficialTelephone: | 3016200012 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | MD | ||||||||
NPICertificationDate: | 03/09/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QA1903X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Surgical |
ID Information
ID | Type | State | Issuer | Description | P00081013 | 01 | MD | RAILROAD MEDICARE | OTHER | RE4 | 01 | MD | BLUE CROSS REGIONAL PLAN | OTHER | 02TI | 01 | MD | BLUE CROSS | OTHER |