Provider Demographics
NPI:1023169752
Name:RIVER ROAD SURGERY CENTER
Entity type:Organization
Organization Name:RIVER ROAD SURGERY CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:BEVERLY
Authorized Official - Middle Name:
Authorized Official - Last Name:LIGHTY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:301-652-7130
Mailing Address - Street 1:5110 RIDGEFIELD ROAD
Mailing Address - Street 2:SUITE 106
Mailing Address - City:BETHESDA
Mailing Address - State:MD
Mailing Address - Zip Code:20816
Mailing Address - Country:US
Mailing Address - Phone:301-652-7130
Mailing Address - Fax:301-652-3170
Practice Address - Street 1:5110 RIDGEFIELD ROAD
Practice Address - Street 2:SUITE 106
Practice Address - City:BETHESDA
Practice Address - State:MD
Practice Address - Zip Code:20816
Practice Address - Country:US
Practice Address - Phone:301-652-7130
Practice Address - Fax:301-652-3170
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-16
Last Update Date:2008-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDA1337261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD300902500Medicaid
MD300902500Medicaid