Provider Demographics
NPI:1396775201
Name:SECURITY AMBULATORY SURGI CENTER, LLC
Entity type:Organization
Organization Name:SECURITY AMBULATORY SURGI CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:GALLOWAY
Authorized Official - Last Name:ROTH
Authorized Official - Suffix:JR
Authorized Official - Credentials:DPM
Authorized Official - Phone:410-455-9660
Mailing Address - Street 1:2 E ROLLING CROSSROADS
Mailing Address - Street 2:SUITE 55
Mailing Address - City:CATONSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21228-6212
Mailing Address - Country:US
Mailing Address - Phone:410-455-9660
Mailing Address - Fax:410-455-9665
Practice Address - Street 1:2 E ROLLING CROSSROADS
Practice Address - Street 2:SUITE 55
Practice Address - City:CATONSVILLE
Practice Address - State:MD
Practice Address - Zip Code:21228-6212
Practice Address - Country:US
Practice Address - Phone:410-455-9660
Practice Address - Fax:410-455-9665
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-04
Last Update Date:2018-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDA1357261QA1903X, 261QP1100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP1100XAmbulatory Health Care FacilitiesClinic/CenterPodiatric
No261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD024DOtherBLUECROSS BLUESHIELD MD
MDRI5OtherCAREFIRST BLUECHOICE
MD3416026OtherAETNA
MD3416026OtherAETNA
MD=========OtherCOVENTRY
MD=========OtherFIDELITY
MD024DOtherBLUECROSS BLUESHIELD MD