1710112669 NPI number — NEWBRIDGE SURGERY CENTER AT WALDORF

Table of content: (NPI 1710112669)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1710112669 NPI number — NEWBRIDGE SURGERY CENTER AT WALDORF

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NEWBRIDGE SURGERY CENTER AT WALDORF
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:
1710112669
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/29/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
196 THOMAS JOHNSON DR
Provider Second Line Business Mailing Address:
SUITE 215
Provider Business Mailing Address City Name:
FREDERICK
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
21702-4397
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
301-668-9988
Provider Business Mailing Address Fax Number:
301-668-9977

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3581 OLD WASHINGTON ROAD
Provider Second Line Business Practice Location Address:
SUITE G
Provider Business Practice Location Address City Name:
WALDORF
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
20602
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
301-638-4400
Provider Business Practice Location Address Fax Number:
301-638-2200
Provider Enumeration Date:
05/21/2009

Additional Information

Authorized Official

Authorized Official Last Name:
GONCHIGAR
Authorized Official First Name:
MRUTHYUNJAYA
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER/PHYSICIAN
Authorized Official Telephone Number:
301-668-9988

Provider Taxonomy Codes

  • Taxonomy code: 261QA1903X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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