Provider Demographics
NPI:1730366394
Name:STANFORD SURGICAL SERVICES LLC
Entity type:Organization
Organization Name:STANFORD SURGICAL SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER PHYSICIAN ASSISTANT
Authorized Official - Prefix:
Authorized Official - First Name:JASON
Authorized Official - Middle Name:CHARLES
Authorized Official - Last Name:STANFORD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:301-528-0868
Mailing Address - Street 1:19466 CARAVAN DR
Mailing Address - Street 2:
Mailing Address - City:GERMANTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:20874-6220
Mailing Address - Country:US
Mailing Address - Phone:301-528-0868
Mailing Address - Fax:
Practice Address - Street 1:19466 CARAVAN DR
Practice Address - Street 2:
Practice Address - City:GERMANTOWN
Practice Address - State:MD
Practice Address - Zip Code:20874-6220
Practice Address - Country:US
Practice Address - Phone:301-528-0868
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-25
Last Update Date:2008-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC0002208363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgicalGroup - Single Specialty