Provider Demographics
NPI:1669448437
Name:SHADY GROVE ORTHOPAEDIC ASSOC, PA
Entity Type:Organization
Organization Name:SHADY GROVE ORTHOPAEDIC ASSOC, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:L
Authorized Official - Last Name:TUCK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:301-340-0072
Mailing Address - Street 1:9601 BLACKWELL ROAD SUITE 100
Mailing Address - Street 2:
Mailing Address - City:ROCKVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20850-3241
Mailing Address - Country:US
Mailing Address - Phone:301-340-0072
Mailing Address - Fax:301-279-9358
Practice Address - Street 1:9601 BLACKWELL ROAD SUITE 100
Practice Address - Street 2:
Practice Address - City:ROCKVILLE
Practice Address - State:MD
Practice Address - Zip Code:20850-3241
Practice Address - Country:US
Practice Address - Phone:301-340-0072
Practice Address - Fax:301-279-9358
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-23
Last Update Date:2020-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0002443207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD4661OtherBLUE SHIELD OF NCA
MDH840SHOtherBLUE SHIELD OF MARYLAND
MD225292OtherMAMSI
MD0549770001OtherADMINISTAR FEDERAL
MDC10224OtherMEDICARE RAILROAD
MDC10224OtherMEDICARE RAILROAD
MD=========OtherNCPPO
MD4661OtherBLUE SHIELD OF NCA
MDC61501Medicare UPIN
MDC10224OtherMEDICARE RAILROAD