Provider Demographics
NPI:1528141025
Name:EASTERN SHORE LITHOTRIPSY
Entity type:Organization
Organization Name:EASTERN SHORE LITHOTRIPSY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:P
Authorized Official - Last Name:KNUD-HANSEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:410-822-5552
Mailing Address - Street 1:6 CAULK LN
Mailing Address - Street 2:
Mailing Address - City:EASTON
Mailing Address - State:MD
Mailing Address - Zip Code:21601-3854
Mailing Address - Country:US
Mailing Address - Phone:410-822-5552
Mailing Address - Fax:410-822-8238
Practice Address - Street 1:6 CAULK LN
Practice Address - Street 2:
Practice Address - City:EASTON
Practice Address - State:MD
Practice Address - Zip Code:21601-3854
Practice Address - Country:US
Practice Address - Phone:410-822-5552
Practice Address - Fax:410-822-8238
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDA1180261QL0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QL0400XAmbulatory Health Care FacilitiesClinic/CenterLithotripsy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD57410502OtherBCBS OF MD PROVIDER NUMBE
MDRV9OtherBCBS OF DC PROVIDER NUMBE
MDRV9OtherBCBS OF DC PROVIDER NUMBE