# PEMBROOKE SQUARE SURGERY CENTER, LLC

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1912993700
- **Authorized official:** MRS. LISA F CONLEY CPC-H (BUSINESS OFFICE MANAGER)
- **Authorized official phone:** (301) 396-8492

## Contact information

- **Practice address:** 11370 PEMBROOKE SQ, WALDORF, MD 20603-4842
- **Practice address phone:** (301) 396-8492
- **Practice address fax:** (301) 396-8498
- **Mailing address:** 11370 PEMBROOKE SQ, WALDORF, MD 20603-4842
- **Mailing address phone:** (301) 396-8492
- **Mailing address fax:** (301) 396-8498

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 261QA1903X | Ambulatory Surgical Clinic/Center | A1407 | MD | Yes |

## Other

- **Enumeration date:** 09/27/2005
- **Last updated:** 11/18/2009

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 01 | — | 3771631 | AETNA HMO | — |
| 05 | — | 407056900 | — | MD |
| 01 | — | 64470501 | BCBS OF MD | MD |
| 01 | — | 7862630 | AETNA PPO | — |
| 01 | — | RT6 | BCBS NATIONAL CAP AREA | DC |