Provider Demographics
NPI:1346581105
Name:MD LASER SURGERY CENTER, LLC
Entity type:Organization
Organization Name:MD LASER SURGERY CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:CLEMENT
Authorized Official - Middle Name:S
Authorized Official - Last Name:BANDA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:443-283-0600
Mailing Address - Street 1:7120 MINSTREL WAY
Mailing Address - Street 2:SUITE 103
Mailing Address - City:COLUMBIA
Mailing Address - State:MD
Mailing Address - Zip Code:21045-5248
Mailing Address - Country:US
Mailing Address - Phone:410-312-5248
Mailing Address - Fax:443-283-0399
Practice Address - Street 1:7120 MINSTREL WAY
Practice Address - Street 2:SUITE 103
Practice Address - City:COLUMBIA
Practice Address - State:MD
Practice Address - Zip Code:21045-5248
Practice Address - Country:US
Practice Address - Phone:410-312-5248
Practice Address - Fax:443-283-0399
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-03-04
Last Update Date:2019-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDA1546261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
549651OtherJOINT COMMISSION ACCR. ORG. ID
MDA1546OtherSTATE LICENSE
549651OtherJOINT COMMISSION ACCR. ORG. ID
21C0001546Medicare Oscar/Certification