Provider Demographics
NPI:1912993700
Name:PEMBROOKE SQUARE SURGERY CENTER, LLC
Entity Type:Organization
Organization Name:PEMBROOKE SQUARE SURGERY CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:LISA
Authorized Official - Middle Name:F
Authorized Official - Last Name:CONLEY
Authorized Official - Suffix:
Authorized Official - Credentials:CPC-H
Authorized Official - Phone:301-396-8492
Mailing Address - Street 1:11370 PEMBROOKE SQ
Mailing Address - Street 2:
Mailing Address - City:WALDORF
Mailing Address - State:MD
Mailing Address - Zip Code:20603-4842
Mailing Address - Country:US
Mailing Address - Phone:301-396-8492
Mailing Address - Fax:301-396-8498
Practice Address - Street 1:11370 PEMBROOKE SQ
Practice Address - Street 2:
Practice Address - City:WALDORF
Practice Address - State:MD
Practice Address - Zip Code:20603-4842
Practice Address - Country:US
Practice Address - Phone:301-396-8492
Practice Address - Fax:301-396-8498
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-27
Last Update Date:2009-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDA1407261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
3771631OtherAETNA HMO
MD407056900Medicaid
MD64470501OtherBCBS OF MD
7862630OtherAETNA PPO
DCRT6OtherBCBS NATIONAL CAP AREA
=========OtherTRICARE
DCRT6OtherBCBS NATIONAL CAP AREA
=========OtherTRICARE