Provider Demographics
NPI:1780011312
Name:PENINSULA SURGICAL GROUP, PA
Entity Type:Organization
Organization Name:PENINSULA SURGICAL GROUP, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SECRETARY/TREASURER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:A
Authorized Official - Last Name:BARTKOVICH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:410-548-2600
Mailing Address - Street 1:804 SNOW HILL RD
Mailing Address - Street 2:
Mailing Address - City:SALISBURY
Mailing Address - State:MD
Mailing Address - Zip Code:21804-1938
Mailing Address - Country:US
Mailing Address - Phone:410-548-2600
Mailing Address - Fax:
Practice Address - Street 1:145 E CARROLL ST
Practice Address - Street 2:
Practice Address - City:SALISBURY
Practice Address - State:MD
Practice Address - Zip Code:21801-5454
Practice Address - Country:US
Practice Address - Phone:410-548-2600
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-09-27
Last Update Date:2013-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR180523363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty