1033861711 NPI number — SHADY GROVE ORTHOPAEDIC ASSOC, PA

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1033861711 NPI number — SHADY GROVE ORTHOPAEDIC ASSOC, PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SHADY GROVE ORTHOPAEDIC ASSOC, PA
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1033861711
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/24/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9601 BLACKWELL RD STE 100
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ROCKVILLE
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
20850-6477
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
19735 GERMANTOWN RD STE 120
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GERMANTOWN
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
20874-1225
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
301-340-9200
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/24/2022

Additional Information

Authorized Official

Authorized Official Last Name:
TUCK
Authorized Official First Name:
STEVEN
Authorized Official Middle Name:
Authorized Official Title or Position:
ORTHOPAEDIC SURGEON/ M.D.
Authorized Official Telephone Number:
301-340-9200

Provider Taxonomy Codes

  • Taxonomy code: 207X00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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