Provider Demographics
NPI:1558463257
Name:SHADY GROVE AMBULATORY SURGERY CENTER,LLC
Entity Type:Organization
Organization Name:SHADY GROVE AMBULATORY SURGERY CENTER,LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:ALLEN
Authorized Official - Last Name:FOOTER
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:301-948-2995
Mailing Address - Street 1:16220 S FREDERICK AVE
Mailing Address - Street 2:SUITE 427
Mailing Address - City:GAITHERSBURG
Mailing Address - State:MD
Mailing Address - Zip Code:20877-4039
Mailing Address - Country:US
Mailing Address - Phone:301-948-2995
Mailing Address - Fax:301-948-6056
Practice Address - Street 1:16220 S FREDERICK AVE
Practice Address - Street 2:SUITE 427
Practice Address - City:GAITHERSBURG
Practice Address - State:MD
Practice Address - Zip Code:20877-4039
Practice Address - Country:US
Practice Address - Phone:301-948-2995
Practice Address - Fax:301-948-6056
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-02
Last Update Date:2009-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDA1135261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDA1135OtherMARYLAND STATE LICENSE #
MDA00070Medicare PIN