Healthcare Provider Details

I. General information

NPI: 1104276211
Provider Name (Legal Business Name): GARRETT ANESTHESIA AND PAIN MANAGEMENT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/20/2016
Last Update Date: 12/16/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

957 NATIONAL HWY
LAVALE MD
21502-7356
US

IV. Provider business mailing address

957 NATIONAL HWY
LAVALE MD
21502-7356
US

V. Phone/Fax

Practice location:
  • Phone: 240-362-7718
  • Fax: 240-362-7731
Mailing address:
  • Phone: 240-362-7128
  • Fax: 240-362-7129

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License NumberD0022148
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number24488
License Number StateMD
# 3
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number07532
License Number StateWV
# 4
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number07755
License Number StateMD

VIII. Authorized Official

Name: DR. MELVIN GONZAGA
Title or Position: OWNER
Credential: MD
Phone: 240-362-7128