Provider Demographics
NPI:1043282775
Name:BALTIMORE ENDOSCOPY ASC LLC
Entity Type:Organization
Organization Name:BALTIMORE ENDOSCOPY ASC LLC
Other - Org Name:GASTROINTESTINAL DIAGNOSTIC CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:
Authorized Official - Last Name:SNODGRASS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-665-1283
Mailing Address - Street 1:1A BURTON HILLS BLVD # L&C
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37215-6187
Mailing Address - Country:US
Mailing Address - Phone:615-240-3820
Mailing Address - Fax:615-234-1720
Practice Address - Street 1:4660 WILKENS AVE
Practice Address - Street 2:SUITE 301
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21229-4848
Practice Address - Country:US
Practice Address - Phone:410-242-3636
Practice Address - Fax:410-242-4404
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-06
Last Update Date:2022-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDA1160261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD0110027Medicaid
MD521911074001OtherSIERRA MILITARY HEALTHCAR
MD21-C0001160Medicare Oscar/Certification
MD521911074001OtherSIERRA MILITARY HEALTHCAR
MD006ZMedicare PIN