Provider Demographics
NPI:1386756161
Name:EYE CARE AND SURGICAL CENTER OF LAUREL PC
Entity type:Organization
Organization Name:EYE CARE AND SURGICAL CENTER OF LAUREL PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:P
Authorized Official - Last Name:GRUNDY
Authorized Official - Suffix:III
Authorized Official - Credentials:MD
Authorized Official - Phone:301-725-3010
Mailing Address - Street 1:615 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:LAUREL
Mailing Address - State:MD
Mailing Address - Zip Code:20707-4065
Mailing Address - Country:US
Mailing Address - Phone:301-725-3010
Mailing Address - Fax:301-725-3271
Practice Address - Street 1:615 MAIN ST
Practice Address - Street 2:
Practice Address - City:LAUREL
Practice Address - State:MD
Practice Address - Zip Code:20707-4065
Practice Address - Country:US
Practice Address - Phone:301-725-3010
Practice Address - Fax:301-725-3271
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2014-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD52388174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD236605300Medicaid
DCG00053Medicare PIN
MD236605300Medicaid