Provider Demographics
NPI:1629094917
Name:ANNAPOLIS ENT SURGICAL CENTER, LLC
Entity Type:Organization
Organization Name:ANNAPOLIS ENT SURGICAL CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:
Authorized Official - Last Name:HEACOCK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:410-841-5279
Mailing Address - Street 1:2002 MEDICAL PARKWAY
Mailing Address - Street 2:SUITE 230A
Mailing Address - City:ANNAPOLIS
Mailing Address - State:MD
Mailing Address - Zip Code:21401-3046
Mailing Address - Country:US
Mailing Address - Phone:410-266-6267
Mailing Address - Fax:410-266-8962
Practice Address - Street 1:2002 MEDICAL PARKWAY
Practice Address - Street 2:SUITE 230A
Practice Address - City:ANNAPOLIS
Practice Address - State:MD
Practice Address - Zip Code:21401-3046
Practice Address - Country:US
Practice Address - Phone:410-266-6267
Practice Address - Fax:410-266-8962
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-13
Last Update Date:2020-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDA1360261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD400841300Medicaid