Provider Demographics
NPI:1588665665
Name:CERTIFIED AMBULATORY SURGERY CENTER
Entity type:Organization
Organization Name:CERTIFIED AMBULATORY SURGERY CENTER
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:LANCE
Authorized Official - Middle Name:G
Authorized Official - Last Name:LEITHAUSE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:301-294-9400
Mailing Address - Street 1:9715 MEDICAL CENTER DR
Mailing Address - Street 2:535
Mailing Address - City:ROCKVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20850-3320
Mailing Address - Country:US
Mailing Address - Phone:301-294-9400
Mailing Address - Fax:301-294-0149
Practice Address - Street 1:9715 MEDICAL CENTER DR
Practice Address - Street 2:535
Practice Address - City:ROCKVILLE
Practice Address - State:MD
Practice Address - Zip Code:20850-3320
Practice Address - Country:US
Practice Address - Phone:301-294-9400
Practice Address - Fax:301-294-0149
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-10
Last Update Date:2011-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDA1225261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD1681001 00Medicaid
MD58426801OtherCF BC/BS MD
MD08820OtherAMERIGROUP
MD0962486OtherAETNA
MD251543OtherMAMSI
MDND9OtherCF BC/BS NCA
MD08820OtherAMERIGROUP