1861818270 NPI number — MID ATLANTIC PAIN MANAGEMENT, LLC

Table of Contents

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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