Provider Demographics
NPI:1285633818
Name:FOUR CORNERS AMBULATORY SURGICAL CENTER LLC
Entity Type:Organization
Organization Name:FOUR CORNERS AMBULATORY SURGICAL CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:A
Authorized Official - Last Name:LIEBERMAN
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:301-681-8400
Mailing Address - Street 1:10101 LORAIN AVE
Mailing Address - Street 2:
Mailing Address - City:SILVER SPRING
Mailing Address - State:MD
Mailing Address - Zip Code:20901-2458
Mailing Address - Country:US
Mailing Address - Phone:301-681-8400
Mailing Address - Fax:301-681-3339
Practice Address - Street 1:10101 LORAIN AVE
Practice Address - Street 2:
Practice Address - City:SILVER SPRING
Practice Address - State:MD
Practice Address - Zip Code:20901-2458
Practice Address - Country:US
Practice Address - Phone:301-681-8400
Practice Address - Fax:301-681-3339
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-15
Last Update Date:2014-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDA1093261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
353620Medicare PIN