MEDICARE: ADVANCED SPINE AND PAIN PLLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207XS0117X	Orthopaedic Surgery of the Spine Physician	0101243103	VA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	DQ1510	OTHER	VA	RRCARE

General Provider Information

NPI Number	:	1255695490
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ADVANCED SPINE AND PAIN PLLC

Provider Business Mailing Address
First Line	:	PO BOX 62234
Second Line	:
City	:	BALTIMORE
State	:	MD
Zip	:	21264-2234
Country	:	US
Telephone Number	:	703-522-2727
Fax Number	:

Provider Business Practice Location Address
First Line	:	2046 JEFFERSON DAVIS HWY
Second Line	:	103
City	:	STAFFORD
State	:	VA
Zip	:	22554-7276
Country	:	US
Telephone Number	:	703-522-2727
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	THOMAS RALEY
Credential	:	MD
Telephone Number	:	703-522-2727

Provider Enumeration Date	:	07/03/2012
Last Update Date	:	08/29/2012

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Directions to “ADVANCED SPINE AND PAIN PLLC ” Practice Location

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