Healthcare Provider Details

I. General information

NPI: 1164796181
Provider Name (Legal Business Name): ANNAPOLIS BACK & NECK CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/08/2012
Last Update Date: 03/08/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

914 BAY RIDGE RD STE 150
ANNAPOLIS MD
21403-3953
US

IV. Provider business mailing address

914 BAY RIDGE RD STE 150
ANNAPOLIS MD
21403-3953
US

V. Phone/Fax

Practice location:
  • Phone: 410-267-0033
  • Fax: 410-267-0444
Mailing address:
  • Phone: 410-267-0033
  • Fax: 410-267-0444

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NS0005X
TaxonomySports Physician Chiropractor
License NumberS01457
License Number StateMD

VIII. Authorized Official

Name: DR. JAMES MICHAEL WAGNER
Title or Position: OWNER
Credential: D.C.
Phone: 410-267-0033