NPI |
1710952841 |
|
Entity Type Code |
2 |
Code describing the type of health care provider that is being assigned an NPI. Codes are 1 = (Person): individual human being who furnishes health care; 2 = (Non-person): entity other than an individual
human being that furnishes health care (for example, hospital, SNF, hospital subunit, pharmacy, or HMO). |
Employer Identification Number EIN |
|
Code describing the type of health care provider that is being assigned an NPI. Codes are 1 = (Person): individual human being who furnishes health care; 2 = (Non-person): entity other than an individual
human being that furnishes health care (for example, hospital, SNF, hospital subunit, pharmacy, or HMO). |
Provider Organization Name Legal Business Name |
ANDOCHICK SURGICAL CENTER LLC |
The name of the organization provider. If the provider is an organization, this is the legal business name. |
Provider Other Organization Name |
PHYSICIANS SURGERY CENTER OF FREDERICK |
The name of the organization provider. If the provider is an organization, this is the legal business name. |
Provider Other Organization Name Type Code |
3 |
Code identifying the type of other name. Codes are: 1 = former name; 2 = professional
name; 3 = doing business as (d/b/ a) name; 4 = former legal business name; 5 = other. |
Provider First Line Business Practice Location Address |
81 THOMAS JOHNSON COURT |
Code identifying the type of other name. Codes are: 1 = former name; 2 = professional
name; 3 = doing business as (d/b/ a) name; 4 = former legal business name; 5 = other. |
Provider Second Line Business Practice Location Address |
SUITE B |
The second line location address of the provider being identified. For providers with more than one physical location, this is the primary location. This address cannot
include a Post Office box. |
Provider Business Practice Location Address City Name |
FREDERICK |
The second line location address of the provider being identified. For providers with more than one physical location, this is the primary location. This address cannot
include a Post Office box. |
Provider Business Practice Location Address State Name |
MD |
The State code in the location of the provider
being identified. |
Provider Business Practice Location Address Postal Code |
21702 |
The State code in the location of the provider
being identified. |
Provider Business Practice Location Address Country Code If outside U S |
US |
The country code in the location address of the provider being identified. |
Provider Business Practice Location Address Telephone Number |
2402153070 |
The country code in the location address of the provider being identified. |
Provider Business Practice Location Address Fax Number |
2402153071 |
The fax number associated with the location
address of the provider being identified. |
Provider Enumeration Date |
2/22/2006 |
The fax number associated with the location
address of the provider being identified. |
Last Update Date |
1/20/2016 |
The date that a record was last updated or changed. |
Authorized Official Last Name |
ANDOCHICK |
The date that a record was last updated or changed. |
Authorized Official First Name |
SCOTT |
The first name of the authorized official. |
Authorized Official Middle Name |
E. |
The first name of the authorized official. |
Authorized Official Title or Position |
OWNER-CHAIRMAN |
The title or position of the authorized official. |
Authorized Official Telephone Number |
3016204200 |
The 10-position telephone number of the authorized official. |
Healthcare Provider Taxonomy Code 1 |
261QA1903X |
Code designating the provider type, classification,
and specialization. Codes are from the Healthcare Provider Taxonomy code list. The NPS will associate these data with the license data for providers with Entity type code = 1. |
Provider License Number 1 |
208200000X |
The license number issued to the provider being identified. The NPS can accommodate
multiple license numbers for multiple specialties and for multiple States. The NPS will associate this data element with ‘‘provider taxonomy code’’. |
Provider License Number State Code 1 |
MD |
|
Healthcare Provider Primary Taxonomy Switch 1 |
N |
|
Healthcare Provider Taxonomy Code 2 |
261QA1903X |
|
Healthcare Provider Primary Taxonomy Switch 2 |
Y |
|
Other Provider Identifier 1 |
420883800 |
Additional number currently or formerly used as an identifier for the provider being identified. This data element will be captured from the NPI application/update form. |
Other Provider Identifier Type Code 1 |
05 |
Code indicating the type of identifier currently
or formerly used by the provider being identified. The codes may reflect UPIN, NSC, OSCAR, DEA, Medicaid State or PIN identification numbers. This data element will be captured from the NPI application/update form. |
Other Provider Identifier State 1 |
MD |
|
Is Organization Subpart |
N |
|
Authorized Official Name Prefix Text |
MR. |
|
Authorized Official Credential Text |
M.D. |
|