Healthcare Provider Details

I. General information

NPI: 1124302690
Provider Name (Legal Business Name): SUMMIT PAIN MANAGEMENT GROUP,INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/03/2011
Last Update Date: 10/03/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

603 REVOLUTION ST
HAVRE DE GRACE MD
21078-3319
US

IV. Provider business mailing address

8056 IANS ALY
LAUREL MD
20724-6133
US

V. Phone/Fax

Practice location:
  • Phone: 410-942-1015
  • Fax: 410-942-1016
Mailing address:
  • Phone: 301-996-9354
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License NumberD0050806
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License NumberD0050806
License Number StateMD
# 3
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License NumberD0050806
License Number StateMD

VIII. Authorized Official

Name: DR. OLAKUNLE TAIWO
Title or Position: PRESIDENT AND C.E.O.
Credential: M.D
Phone: 301-996-9354