1669448437 NPI number — SHADY GROVE ORTHOPAEDIC ASSOC, PA

Table of content: (NPI 1669448437)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1669448437 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:
1669448437
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/23/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9601 BLACKWELL ROAD SUITE 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:
20850-3241
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
301-340-0072
Provider Business Mailing Address Fax Number:
301-279-9358

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9601 BLACKWELL ROAD SUITE 100
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ROCKVILLE
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
20850-3241
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
301-340-0072
Provider Business Practice Location Address Fax Number:
301-279-9358
Provider Enumeration Date:
02/23/2006

Additional Information

Authorized Official

Authorized Official Last Name:
TUCK
Authorized Official First Name:
STEVEN
Authorized Official Middle Name:
L
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
301-340-0072

Provider Taxonomy Codes

  • Taxonomy code: 207X00000X , with the licence number:  D0002443 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 4661 . This is a "BLUE SHIELD OF NCA" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: H840SH . This is a "BLUE SHIELD OF MARYLAND" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: 225292 . This is a "MAMSI" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: 0549770001 . This is a "ADMINISTAR FEDERAL" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: C10224 . This is a "MEDICARE RAILROAD" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".




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