Provider Demographics
NPI:1730187337
Name:MT AIRY SURGERY CENTER, LLC
Entity type:Organization
Organization Name:MT AIRY SURGERY CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SR VICE PRESIDENT-FINANCE
Authorized Official - Prefix:
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:K
Authorized Official - Last Name:KELBY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:410-848-3000
Mailing Address - Street 1:1001 TWIN ARCH RD
Mailing Address - Street 2:SUITE 3C
Mailing Address - City:MOUNT AIRY
Mailing Address - State:MD
Mailing Address - Zip Code:21771-4138
Mailing Address - Country:US
Mailing Address - Phone:410-549-2100
Mailing Address - Fax:410-549-2807
Practice Address - Street 1:1001 TWIN ARCH RD
Practice Address - Street 2:SUITE 3C
Practice Address - City:MOUNT AIRY
Practice Address - State:MD
Practice Address - Zip Code:21771-4138
Practice Address - Country:US
Practice Address - Phone:410-549-2100
Practice Address - Fax:410-549-2807
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-08
Last Update Date:2009-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDA1089261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD430400400Medicaid
MD430400400Medicaid