1184665069 NPI number — DECK PAIN MANAGEMENT , LLC

Table of content: (NPI 1184665069)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1184665069 NPI number — DECK PAIN MANAGEMENT , LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DECK PAIN MANAGEMENT , LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1184665069
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/19/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
11921 ROCKVILLE PIKE
Provider Second Line Business Mailing Address:
SUITE 505
Provider Business Mailing Address City Name:
ROCKVILLE
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
20852-2737
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
410-265-7300
Provider Business Mailing Address Fax Number:
410-265-9533

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
75 THOMAS JOHNSON DR
Provider Second Line Business Practice Location Address:
SUITE C
Provider Business Practice Location Address City Name:
FREDERICK
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21702-4895
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
301-620-0012
Provider Business Practice Location Address Fax Number:
301-620-9687
Provider Enumeration Date:
06/09/2006

Additional Information

Authorized Official

Authorized Official Last Name:
LOEV
Authorized Official First Name:
MARC
Authorized Official Middle Name:
Authorized Official Title or Position:
PHYSICIAN/OWNER
Authorized Official Telephone Number:
301-881-7246

Provider Taxonomy Codes

  • Taxonomy code: 208VP0014X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 308CCE . This is a "BLUE CROSS" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: K907 . This is a "BLUE CROSS" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: DE8894 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".




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