Provider Demographics
NPI:1972658706
Name:FREDERICKTOWN AMBULATORY SURGICAL FACILITY, INC.
Entity Type:Organization
Organization Name:FREDERICKTOWN AMBULATORY SURGICAL FACILITY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESEIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:VINCENT
Authorized Official - Middle Name:EDWIN
Authorized Official - Last Name:DIFABIO
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:3016-904-0870
Mailing Address - Street 1:198 THOMAS JOHNSON DR
Mailing Address - Street 2:SUITE 101
Mailing Address - City:FREDERICK
Mailing Address - State:MD
Mailing Address - Zip Code:21702-4398
Mailing Address - Country:US
Mailing Address - Phone:301-694-0870
Mailing Address - Fax:301-694-7034
Practice Address - Street 1:198 THOMAS JOHNSON DR
Practice Address - Street 2:SUITE 101
Practice Address - City:FREDERICK
Practice Address - State:MD
Practice Address - Zip Code:21702-4398
Practice Address - Country:US
Practice Address - Phone:301-694-0870
Practice Address - Fax:301-694-7034
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-24
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDA1166261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD=========OtherFEDERAL TAX ID NUMBER