Healthcare Provider Details

I. General information

NPI: 1053670430
Provider Name (Legal Business Name): MARYLAND INTERVENTIONAL PAIN MANAGEMENT, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/07/2012
Last Update Date: 05/07/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1147 S HANOVER ST
BALTIMORE MD
21230-3717
US

IV. Provider business mailing address

5430 CAMPBELL BLVD SUITE 106
WHITE MARSH MD
21162-5500
US

V. Phone/Fax

Practice location:
  • Phone: 443-725-4930
  • Fax: 443-725-4933
Mailing address:
  • Phone: 443-725-4930
  • Fax: 443-725-4933

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number3825
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number3868
License Number StateMD
# 3
Primary TaxonomyN
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number3470
License Number StateMD
# 4
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number60828
License Number StateMD

VIII. Authorized Official

Name: MR. TIMOTHY J GOBER
Title or Position: PRESIDENT
Credential: DC
Phone: 443-725-4930