1811084304 NPI number — PENINSULA SURGICAL GROUP, P.A.

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 1811084304 NPI number — PENINSULA SURGICAL GROUP, P.A.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PENINSULA SURGICAL GROUP, P.A.
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:
6
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:
1811084304
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 3317
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SALISBURY
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
21802-3317
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
410-548-2600
Provider Business Mailing Address Fax Number:
410-548-2607

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
145 EAST CARROLL STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SALISBURY
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21801-5454
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
410-546-8400
Provider Business Practice Location Address Fax Number:
410-548-2707
Provider Enumeration Date:
10/06/2006

Additional Information

Authorized Official

Authorized Official Last Name:
DUDAS
Authorized Official First Name:
NICHOLAS
Authorized Official Middle Name:
J.
Authorized Official Title or Position:
PHYSICIAN
Authorized Official Telephone Number:
410-548-2600

Provider Taxonomy Codes

  • Taxonomy code: 261QR0206X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





Copyright © 2007-2025 www.npivalidator.com