Provider Demographics
NPI:1245620871
Name:ADVANTIA SURGICAL LLC
Entity type:Organization
Organization Name:ADVANTIA SURGICAL LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHIEF MEDICAL OFFICER
Authorized Official - Prefix:DR
Authorized Official - First Name:PETER
Authorized Official - Middle Name:
Authorized Official - Last Name:GLASS
Authorized Official - Suffix:
Authorized Official - Credentials:MB CHB FFA (SA)
Authorized Official - Phone:240-560-5092
Mailing Address - Street 1:12240 INDIAN CREEK CT STE 130
Mailing Address - Street 2:
Mailing Address - City:BELTSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20705-1260
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:12240 INDIAN CREEK CT STE 130
Practice Address - Street 2:
Practice Address - City:BELTSVILLE
Practice Address - State:MD
Practice Address - Zip Code:20705-1260
Practice Address - Country:US
Practice Address - Phone:240-560-5092
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ADVANTIA HOLDINGS OF MARYLAND LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-02-03
Last Update Date:2017-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD582166OtherTHE JOINT COMMISSION CERTIFICATION
MDA1572OtherMD STATE ASC LICENSE
MD582166OtherTHE JOINT COMMISSION CERTIFICATION
MD454377Medicare PIN