Healthcare Provider Details

I. General information

NPI: 1902348659
Provider Name (Legal Business Name): 1ST MEDICAL PAIN MANAGEMENT SPECIALISTS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/11/2016
Last Update Date: 01/23/2022
Certification Date: 01/23/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20 MAYO RD STE 201
EDGEWATER MD
21037-1442
US

IV. Provider business mailing address

20 MAYO RD SUITE 201
EDGEWATER MD
21037-1439
US

V. Phone/Fax

Practice location:
  • Phone: 410-956-6800
  • Fax: 410-956-6803
Mailing address:
  • Phone: 410-956-6800
  • Fax: 410-956-6803

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code171W00000X
TaxonomyContractor
License NumberD40904
License Number StateMD
# 4
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code261QP3300X
TaxonomyPain Clinic/Center
License Number
License Number State
# 8
Primary TaxonomyN
Taxonomy Code261QR0400X
TaxonomyRehabilitation Clinic/Center
License Number
License Number State
# 9
Primary TaxonomyN
Taxonomy Code261QR0401X
TaxonomyComprehensive Outpatient Rehabilitation Facility (CORF)
License Number
License Number State
# 10
Primary TaxonomyN
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: ROSEMARY INGADO
Title or Position: CLINICAL ADMINISTRATOR
Credential: PA
Phone: 410-956-6800