Provider Demographics
NPI:1902959190
Name:RIVA ROAD SURGICAL CENTER, LLC
Entity Type:Organization
Organization Name:RIVA ROAD SURGICAL CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICER/AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:NIKKI
Authorized Official - Middle Name:
Authorized Official - Last Name:CASTEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:808-772-7818
Mailing Address - Street 1:2635 RIVA RD STE 118
Mailing Address - Street 2:
Mailing Address - City:ANNAPOLIS
Mailing Address - State:MD
Mailing Address - Zip Code:21401-7430
Mailing Address - Country:US
Mailing Address - Phone:410-571-9595
Mailing Address - Fax:410-571-9590
Practice Address - Street 1:2635 RIVA RD STE 118
Practice Address - Street 2:
Practice Address - City:ANNAPOLIS
Practice Address - State:MD
Practice Address - Zip Code:21401-7430
Practice Address - Country:US
Practice Address - Phone:410-571-9595
Practice Address - Fax:410-571-9590
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-19
Last Update Date:2022-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDPENDING261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD21C00001449Medicare UPIN