Basic Information
| Provider Information | |||||||||
| NPI: | 1962417634 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | UNIVERSITY OF MARYLAND SURGICAL ASSOCIATES, PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 64226 | ||||||||
| Address2: | |||||||||
| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212644226 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4103285191 | ||||||||
| FaxNumber: | 4103282109 | ||||||||
| Practice Location | |||||||||
| Address1: | 419 W REDWOOD ST | ||||||||
| Address2: | |||||||||
| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212011734 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6672141718 | ||||||||
| FaxNumber: | 4103285147 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/30/2006 | ||||||||
| LastUpdateDate: | 04/27/2021 | ||||||||
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| AuthorizedOfficialLastName: | LAU | ||||||||
| AuthorizedOfficialFirstName: | CHRISTINA | ||||||||
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| AuthorizedOfficialTitleorPosition: | DEPARTMENT CHAIRMAN | ||||||||
| AuthorizedOfficialTelephone: | 4103286019 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | 04/27/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | Y | 193200000X MULTI-SPECIALTY GROUP | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 914651200 | 05 | MD | MEDICAID |