Healthcare Provider Details

I. General information

NPI: 1053765651
Provider Name (Legal Business Name): OLNEY PAIN CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/20/2016
Last Update Date: 04/20/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3413 OLANDWOOD CT STE 103
OLNEY MD
20832-1489
US

IV. Provider business mailing address

3413 OLANDWOOD CT STE 103
OLNEY MD
20832-1489
US

V. Phone/Fax

Practice location:
  • Phone: 301-774-1622
  • Fax: 301-774-0488
Mailing address:
  • Phone: 301-774-1622
  • Fax: 301-774-0488

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number140799
License Number StateMD

VIII. Authorized Official

Name: JONATHAN LEVIN
Title or Position: PRESIDENT
Credential: M.D.
Phone: 301-774-1622