Provider Demographics
NPI:1619052891
Name:ADVANCED CENTERS FOR ORTHOPEDIC SURGERY AND SPORTS MEDICINE
Entity Type:Organization
Organization Name:ADVANCED CENTERS FOR ORTHOPEDIC SURGERY AND SPORTS MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:GEOFF
Authorized Official - Middle Name:
Authorized Official - Last Name:FAILLA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:410-484-8088
Mailing Address - Street 1:PO BOX 759190
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21275-9190
Mailing Address - Country:US
Mailing Address - Phone:410-484-8088
Mailing Address - Fax:410-581-9485
Practice Address - Street 1:1 VILLAGE SQ
Practice Address - Street 2:
Practice Address - City:WESTMINSTER
Practice Address - State:MD
Practice Address - Zip Code:21157-6145
Practice Address - Country:US
Practice Address - Phone:410-876-8077
Practice Address - Fax:410-876-8154
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ADVANCED CENTER FOR ORTHOPEDIC SURGERY AND SPORTS MEDICINE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-10-26
Last Update Date:2008-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDA1251R261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDA1251ROtherLICENSE #
MD066ZMedicare PIN
MDA1251ROtherLICENSE #