1356645451 NPI number — PLASTIC SURGERY CENTER OF SOUTHERN MARYLAND, LLC

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 1356645451 NPI number — PLASTIC SURGERY CENTER OF SOUTHERN MARYLAND, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PLASTIC SURGERY CENTER OF SOUTHERN MARYLAND, LLC
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:
1356645451
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/11/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
70 SHERRY LN STE 203
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PRINCE FREDERICK
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
20678-3275
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
410-414-9844
Provider Business Mailing Address Fax Number:
410-414-9795

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
70 SHERRY LN STE 203
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PRINCE FREDERICK
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
20678-3275
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
410-414-9844
Provider Business Practice Location Address Fax Number:
410-414-9795
Provider Enumeration Date:
01/04/2011

Additional Information

Authorized Official

Authorized Official Last Name:
EHRMANTRAUT
Authorized Official First Name:
WILFRED
Authorized Official Middle Name:
RUSSELL
Authorized Official Title or Position:
PRESIDENT OF ORGANIZATION/SURGEON
Authorized Official Telephone Number:
410-414-9844

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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