Provider Demographics
NPI:1871504803
Name:SLADE ASC, LLC
Entity Type:Organization
Organization Name:SLADE ASC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:ALAN
Authorized Official - Last Name:GRUEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:410-654-5700
Mailing Address - Street 1:10 CROSSROADS DRIVE
Mailing Address - Street 2:SUITE 104
Mailing Address - City:OWINGS MILLS
Mailing Address - State:MD
Mailing Address - Zip Code:21117
Mailing Address - Country:US
Mailing Address - Phone:410-654-5700
Mailing Address - Fax:410-654-5399
Practice Address - Street 1:10 CROSSROADS DRIVE
Practice Address - Street 2:SUITE 104
Practice Address - City:OWINGS MILLS
Practice Address - State:MD
Practice Address - Zip Code:21117
Practice Address - Country:US
Practice Address - Phone:410-654-5700
Practice Address - Fax:410-654-5399
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-11
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0025907261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD052ZMedicare ID - Type Unspecified
D67340Medicare UPIN