Provider Demographics
NPI:1194222620
Name:SHADY GROVE SURGERY CENTER LLC
Entity Type:Organization
Organization Name:SHADY GROVE SURGERY CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KATHY
Authorized Official - Middle Name:MICHELLE
Authorized Official - Last Name:JONES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:240-912-4546
Mailing Address - Street 1:2403 RESEARCH BLVD STE 200
Mailing Address - Street 2:
Mailing Address - City:ROCKVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20850-6289
Mailing Address - Country:US
Mailing Address - Phone:240-912-4546
Mailing Address - Fax:240-912-4471
Practice Address - Street 1:2403 RESEARCH BLVD STE 200
Practice Address - Street 2:
Practice Address - City:ROCKVILLE
Practice Address - State:MD
Practice Address - Zip Code:20850-6289
Practice Address - Country:US
Practice Address - Phone:240-912-4546
Practice Address - Fax:240-912-4471
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-04-11
Last Update Date:2018-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty