Healthcare Provider Details

I. General information

NPI: 1861628521
Provider Name (Legal Business Name): PENINSULA PAIN MANAGEMENT, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/08/2009
Last Update Date: 12/08/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13014 RIGGIN RIDGE RD
OCEAN CITY MD
21842-9716
US

IV. Provider business mailing address

13014 RIGGIN RIDGE RD
OCEAN CITY MD
21842-9716
US

V. Phone/Fax

Practice location:
  • Phone: 443-783-3543
  • Fax:
Mailing address:
  • Phone: 443-783-3543
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License NumberD0035246
License Number StateMD
# 5
Primary TaxonomyY
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License NumberD0035246
License Number StateMD

VIII. Authorized Official

Name: BRENT FOX
Title or Position: OWNER
Credential:
Phone: 443-783-3543