Provider Demographics
NPI:1295750594
Name:ST. MARY'S MULTI-SPECIALTY SURGERY CENTRE, INC.
Entity type:Organization
Organization Name:ST. MARY'S MULTI-SPECIALTY SURGERY CENTRE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:
Authorized Official - Last Name:HALLGREN
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:301-862-3338
Mailing Address - Street 1:PO BOX 1310
Mailing Address - Street 2:
Mailing Address - City:CALIFORNIA
Mailing Address - State:MD
Mailing Address - Zip Code:20619-1310
Mailing Address - Country:US
Mailing Address - Phone:301-862-3338
Mailing Address - Fax:301-862-3335
Practice Address - Street 1:22325 GREENVIEW PKWY
Practice Address - Street 2:
Practice Address - City:GREAT MILLS
Practice Address - State:MD
Practice Address - Zip Code:20634-4404
Practice Address - Country:US
Practice Address - Phone:301-862-3338
Practice Address - Fax:301-862-3335
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-13
Last Update Date:2008-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDA1147261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
021ZMedicare PIN