Provider Demographics
NPI:1669426706
Name:ADVANCED SURGERY CENTER,LLC
Entity type:Organization
Organization Name:ADVANCED SURGERY CENTER,LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CLINICAL ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:CLAY
Authorized Official - Last Name:LACAVA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:301-838-0437
Mailing Address - Street 1:10110 MOLECULAR DRIVE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:ROCKVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20850
Mailing Address - Country:US
Mailing Address - Phone:301-838-0437
Mailing Address - Fax:301-838-0439
Practice Address - Street 1:10110 MOLECULAR DRIVE
Practice Address - Street 2:SUITE 100
Practice Address - City:ROCKVILLE
Practice Address - State:MD
Practice Address - Zip Code:20850
Practice Address - Country:US
Practice Address - Phone:301-838-0437
Practice Address - Fax:301-838-0439
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ADVANCED SURGERY CENTER, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-05-22
Last Update Date:2015-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDA1400261QE0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0800XAmbulatory Health Care FacilitiesClinic/CenterEndoscopy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD405873900Medicaid
MDA00057Medicare ID - Type UnspecifiedTRAILBLAZERS