Healthcare Provider Details

I. General information

NPI: 1669008330
Provider Name (Legal Business Name): PAIN AND SPINE SPECIALISTS OF MARYLAND, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/13/2020
Last Update Date: 03/13/2020
Certification Date: 03/13/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6816 DEERPATH RD STE 201
ELKRIDGE MD
21075-6200
US

IV. Provider business mailing address

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

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QR0401X
TaxonomyComprehensive Outpatient Rehabilitation Facility (CORF)
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number StateNULL

VIII. Authorized Official

Name: STACI POWELL
Title or Position: BILLING MANAGER
Credential:
Phone: 301-703-8767