Provider Demographics
NPI:1437106846
Name:ANTIETAM UROSURGICAL CENTER LLC ASC
Entity Type:Organization
Organization Name:ANTIETAM UROSURGICAL CENTER LLC ASC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:DEBBIE
Authorized Official - Middle Name:K
Authorized Official - Last Name:KLAUKA
Authorized Official - Suffix:
Authorized Official - Credentials:MBA
Authorized Official - Phone:301-665-4879
Mailing Address - Street 1:PO BOX 37768
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21297-3768
Mailing Address - Country:US
Mailing Address - Phone:301-733-0022
Mailing Address - Fax:301-733-3461
Practice Address - Street 1:11110 MEDICAL CAMPUS RD
Practice Address - Street 2:SUITE 228
Practice Address - City:HAGERSTOWN
Practice Address - State:MD
Practice Address - Zip Code:21742-6700
Practice Address - Country:US
Practice Address - Phone:301-733-0022
Practice Address - Fax:301-733-3461
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-30
Last Update Date:2016-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDA1224261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
21C0001224OtherCCN
21C0001224OtherCCN