Provider Demographics
NPI:1720128929
Name:BELCREST SURGERY CENTER, LLC
Entity Type:Organization
Organization Name:BELCREST SURGERY CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER/LEADING MEMB
Authorized Official - Prefix:
Authorized Official - First Name:JOHNY
Authorized Official - Middle Name:
Authorized Official - Last Name:MOTRAN
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:301-699-5900
Mailing Address - Street 1:PO BOX 86284
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY VILLAGE
Mailing Address - State:MD
Mailing Address - Zip Code:20886-6284
Mailing Address - Country:US
Mailing Address - Phone:301-699-5900
Mailing Address - Fax:301-699-9297
Practice Address - Street 1:6505 BELCREST RD
Practice Address - Street 2:SUITE 1
Practice Address - City:HYATTSVILLE
Practice Address - State:MD
Practice Address - Zip Code:20782-2011
Practice Address - Country:US
Practice Address - Phone:301-699-5900
Practice Address - Fax:301-699-9297
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-07
Last Update Date:2014-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
174400000X
MD01450213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
No174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD1114256062Medicare UPIN
MD6342390001Medicare NSC