Provider Demographics
NPI:1811084304
Name:PENINSULA SURGICAL GROUP, P.A.
Entity type:Organization
Organization Name:PENINSULA SURGICAL GROUP, P.A.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:NICHOLAS
Authorized Official - Middle Name:J
Authorized Official - Last Name:DUDAS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:410-548-2600
Mailing Address - Street 1:PO BOX 3317
Mailing Address - Street 2:
Mailing Address - City:SALISBURY
Mailing Address - State:MD
Mailing Address - Zip Code:21802-3317
Mailing Address - Country:US
Mailing Address - Phone:410-548-2600
Mailing Address - Fax:410-548-2607
Practice Address - Street 1:145 EAST CARROLL STREET
Practice Address - Street 2:
Practice Address - City:SALISBURY
Practice Address - State:MD
Practice Address - Zip Code:21801-5454
Practice Address - Country:US
Practice Address - Phone:410-546-8400
Practice Address - Fax:410-548-2707
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-06
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0206XAmbulatory Health Care FacilitiesClinic/CenterRadiology, Mammography
Provider Identifiers
StateIdentifier IDID TypeIssuer
S060Medicare ID - Type Unspecified