Healthcare Provider Details

I. General information

NPI: 1477192730
Provider Name (Legal Business Name): PAIN AND SPINE SPECIALISTS OF MARYLAND, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/03/2020
Last Update Date: 01/03/2020
Certification Date: 01/03/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6816 DEERPATH RD STE 205
ELKRIDGE MD
21075-6200
US

IV. Provider business mailing address

2702 BACK ACRE CIR # 290B
MOUNT AIRY MD
21771-7769
US

V. Phone/Fax

Practice location:
  • Phone: 301-703-8767
  • Fax: 301-703-8886
Mailing address:
  • Phone: 301-703-8767
  • Fax: 301-703-8886

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 Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code103TA0400X
TaxonomyAddiction (Substance Use Disorder) Psychologist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: SUDHIR R RAO
Title or Position: OWNER
Credential: MD
Phone: 301-703-8767