Provider Demographics
NPI:1710079470
Name:SURGERY CENTER OF POTOMAC LLC
Entity Type:Organization
Organization Name:SURGERY CENTER OF POTOMAC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ADAM
Authorized Official - Middle Name:GASTON
Authorized Official - Last Name:TATTELBAUM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:240-747-5631
Mailing Address - Street 1:3203 TOWER OAKS BLVD
Mailing Address - Street 2:#100
Mailing Address - City:ROCKVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20852
Mailing Address - Country:US
Mailing Address - Phone:240-747-5631
Mailing Address - Fax:301-754-2503
Practice Address - Street 1:3203 TOWER OAKS BLVD
Practice Address - Street 2:#100
Practice Address - City:ROCKVILLE
Practice Address - State:MD
Practice Address - Zip Code:20852
Practice Address - Country:US
Practice Address - Phone:240-747-5631
Practice Address - Fax:301-754-2503
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-29
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDA1404261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
A00063Medicare ID - Type Unspecified