Provider Demographics
NPI:1528096690
Name:SUBURBAN HOSPITAL, INC.
Entity type:Organization
Organization Name:SUBURBAN HOSPITAL, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:A
Authorized Official - Last Name:GRAGNOLATI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:301-896-2574
Mailing Address - Street 1:8600 OLD GEORGETOWN RD
Mailing Address - Street 2:
Mailing Address - City:BETHESDA
Mailing Address - State:MD
Mailing Address - Zip Code:20814-1422
Mailing Address - Country:US
Mailing Address - Phone:301-896-3901
Mailing Address - Fax:
Practice Address - Street 1:6420 ROCKLEDGE DR
Practice Address - Street 2:SUITE 1200
Practice Address - City:BETHESDA
Practice Address - State:MD
Practice Address - Zip Code:20817-7837
Practice Address - Country:US
Practice Address - Phone:301-896-3901
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SUBURBAN HOSPITAL, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-06-29
Last Update Date:2011-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD15332261Q00000X, 261QI0500X, 261QX0203X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QX0203XAmbulatory Health Care FacilitiesClinic/CenterOncology, Radiation
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No261QI0500XAmbulatory Health Care FacilitiesClinic/CenterInfusion Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC715OtherBLUE CROSS OF NCA
MD419126900Medicaid
MD57352101OtherBLUE CROSS OF MARYLAND
DC715OtherBLUE CROSS OF NCA