Provider Demographics
NPI:1376542076
Name:FREDERICK SURGICAL CENTER, LLC
Entity Type:Organization
Organization Name:FREDERICK SURGICAL CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EVP AND COO
Authorized Official - Prefix:MR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:A
Authorized Official - Last Name:NEWMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:405-608-1709
Mailing Address - Street 1:14000 N. PORTLAND AVENUE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73134-4004
Mailing Address - Country:US
Mailing Address - Phone:405-608-1766
Mailing Address - Fax:405-608-1866
Practice Address - Street 1:45 THOMAS JOHNSON DRIVE
Practice Address - Street 2:SUITE 207
Practice Address - City:FREDERICK
Practice Address - State:MD
Practice Address - Zip Code:21702
Practice Address - Country:US
Practice Address - Phone:301-694-3400
Practice Address - Fax:301-694-3620
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
MDA1039261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDZZ70OtherMEDICARE PROVIDER NUMBER
MD414472400Medicaid
MD269918OtherMAMSI