Basic Information
| Provider Information | |||||||||
| NPI: | 1043457468 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MID ATLANTIC SKIN SURGERY INSTITUTE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 26840 POINT LOOKOUT ROAD | ||||||||
| Address2: | PO BOX 1409 | ||||||||
| City: | LEONARDTOWN | ||||||||
| State: | MD | ||||||||
| PostalCode: | 206501409 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3014758091 | ||||||||
| FaxNumber: | 3014756712 | ||||||||
| Practice Location | |||||||||
| Address1: | 173 SAINT PATRICKS DR | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | WALDORF | ||||||||
| State: | MD | ||||||||
| PostalCode: | 206035529 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3014758091 | ||||||||
| FaxNumber: | 3014726712 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/08/2009 | ||||||||
| LastUpdateDate: | 01/08/2009 | ||||||||
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| AuthorizedOfficialLastName: | VERGHESE | ||||||||
| AuthorizedOfficialFirstName: | KANNARKAT | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 3014758091 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ND0101X | D0065320 | MD | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Dermatology | MOHS-Micrographic Surgery |
No ID Information.