1285121749 NPI number — PROVIDENCE PAIN MANAGEMENT CENTER, P.A.

Table of content: (NPI 1285121749)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1285121749 NPI number — PROVIDENCE PAIN MANAGEMENT CENTER, P.A.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PROVIDENCE PAIN MANAGEMENT CENTER, P.A.
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:
INNOVATIVE LABORATORIES
Provider Other Organization Name Type Code:
3
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:
1285121749
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/13/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6911 LAUREL BOWIE RD STE 212B
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BOWIE
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
20715-1712
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
301-755-9500
Provider Business Mailing Address Fax Number:
301-747-6017

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6911 LAUREL BOWIE RD STE 212B
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BOWIE
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
20715-1712
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
301-755-9500
Provider Business Practice Location Address Fax Number:
301-747-6017
Provider Enumeration Date:
04/19/2018

Additional Information

Authorized Official

Authorized Official Last Name:
OPPONG
Authorized Official First Name:
JOSEPH
Authorized Official Middle Name:
MAXWELL
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
301-750-9500

Provider Taxonomy Codes

  • Taxonomy code: 291U00000X , with the licence number:  21D2142104 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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