1801952346 NPI number — KENILWORTH SURGERY CENTER LLC

Table of content: KELLEY ANN TRAISTER MSW (NPI 1588921449)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1801952346 NPI number — KENILWORTH SURGERY CENTER LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
KENILWORTH SURGERY CENTER 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:
1801952346
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/10/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1104 KENILWORTH DR
Provider Second Line Business Mailing Address:
STE 201
Provider Business Mailing Address City Name:
TOWSON
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
21204
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
443-279-0340
Provider Business Mailing Address Fax Number:
443-279-0343

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1104 KENILWORTH DR
Provider Second Line Business Practice Location Address:
STE 201
Provider Business Practice Location Address City Name:
TOWSON
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21204
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
443-279-0340
Provider Business Practice Location Address Fax Number:
443-279-0343
Provider Enumeration Date:
12/29/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MILLER
Authorized Official First Name:
STANLEY
Authorized Official Middle Name:
J
Authorized Official Title or Position:
MEDICAL DIRECTOR
Authorized Official Telephone Number:
443-279-0340

Provider Taxonomy Codes

  • Taxonomy code: 208600000X , with the licence number:  A1367 , 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)





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