1003283938 NPI number — MID ATLANTIC PAIN MANAGEMENT, LLC

Table of content: (NPI 1003283938)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1003283938 NPI number — MID ATLANTIC PAIN MANAGEMENT, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MID ATLANTIC 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:
1003283938
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/26/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1302 RISING RIDGE RD
Provider Second Line Business Mailing Address:
SUITE 1
Provider Business Mailing Address City Name:
MOUNT AIRY
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
21771-5790
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
301-829-7683
Provider Business Mailing Address Fax Number:
301-829-7694

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3930 PENDER DR
Provider Second Line Business Practice Location Address:
SUITE 120
Provider Business Practice Location Address City Name:
FAIRFAX
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
22030-0985
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
301-829-7693
Provider Business Practice Location Address Fax Number:
301-829-7694
Provider Enumeration Date:
08/26/2015

Additional Information

Authorized Official

Authorized Official Last Name:
ANDERSON
Authorized Official First Name:
LEWIE
Authorized Official Middle Name:
G
Authorized Official Title or Position:
COO
Authorized Official Telephone Number:
301-829-7683

Provider Taxonomy Codes

  • Taxonomy code: 207L00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207LP2900X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0352193 . This is a "AETNA HMO" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1861818270 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: BE66 . This is a "CAREFIRST BCBS" identifier . This identifiers is of the category "OTHER".
  • Identifier: DV0457 . This is a "RAILROAD MEDICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 5395974 . This is a "AETNA NON-HMO" identifier . This identifiers is of the category "OTHER".
  • Identifier: 618183700 . This is a "USDOL OWCP" identifier . This identifiers is of the category "OTHER".




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