Healthcare Provider Details

I. General information

NPI: 1033665450
Provider Name (Legal Business Name): MATSUNAGA PAIN MANAGEMENT LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/26/2016
Last Update Date: 08/26/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9755 PATUXENT WOODS DR SUITE 100
COLUMBIA MD
21046-2286
US

IV. Provider business mailing address

8894 STANFORD BLVD SUITE 104
COLUMBIA MD
21045-4794
US

V. Phone/Fax

Practice location:
  • Phone: 410-218-3458
  • Fax:
Mailing address:
  • Phone: 410-997-7246
  • Fax: 410-997-7226

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number21D2117103
License Number StateMD

VIII. Authorized Official

Name: TIM KARTISEK
Title or Position: BILLING SUPERVISOR
Credential:
Phone: 443-371-7749