1861818270 NPI number — MID ATLANTIC PAIN MANAGEMENT, LLC

Table of content: (NPI 1861818270)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1861818270 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:
1861818270
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/07/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 610624
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DALLAS
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75261-0624
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
800-394-4445
Provider Business Mailing Address Fax Number:
706-650-1034

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6355 WALKER LN
Provider Second Line Business Practice Location Address:
SUITE 200
Provider Business Practice Location Address City Name:
ALEXANDRIA
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
22310-3245
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
301-829-7683
Provider Business Practice Location Address Fax Number:
301-829-7694
Provider Enumeration Date:
03/10/2014

Additional Information

Authorized Official

Authorized Official Last Name:
WOODS
Authorized Official First Name:
BRIAN
Authorized Official Middle Name:
P
Authorized Official Title or Position:
CHIEF MEDICAL OFFICER
Authorized Official Telephone Number:
214-687-0015

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: 618183700 . This is a "USDOL OWCP - FEDERAL BLACK LUNG" identifier . This identifiers is of the category "OTHER".
  • Identifier: 618183700 . This is a "USDOL OWCP - DEEOIC" identifier . This identifiers is of the category "OTHER".
  • Identifier: DV0457 . This is a "RAILROAD MEDICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: BE66 . This is a "CAREFIRST BC/BS" identifier . This identifiers is of the category "OTHER".




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