1043457468 NPI number — MID ATLANTIC SKIN SURGERY INSTITUTE

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 1043457468 NPI number — MID ATLANTIC SKIN SURGERY INSTITUTE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MID ATLANTIC SKIN SURGERY INSTITUTE
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:
1043457468
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/11/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
173 SAINT PATRICKS DR STE 201
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WALDORF
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
20603-5531
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
301-396-3401
Provider Business Mailing Address Fax Number:
301-396-3403

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
173 SAINT PATRICKS DR
Provider Second Line Business Practice Location Address:
SUITE 201
Provider Business Practice Location Address City Name:
WALDORF
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
20603-5529
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
301-475-8091
Provider Business Practice Location Address Fax Number:
301-472-6712
Provider Enumeration Date:
01/08/2009

Additional Information

Authorized Official

Authorized Official Last Name:
VERGHESE
Authorized Official First Name:
GEORGE
Authorized Official Middle Name:
KANNARKAT
Authorized Official Title or Position:
MEDICAL DIRECTOR
Authorized Official Telephone Number:
301-396-3401

Provider Taxonomy Codes

  • Taxonomy code: 207ND0101X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207N00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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