Healthcare Provider Details

I. General information

NPI: 1174917736
Provider Name (Legal Business Name): PAIN TREATMENT CENTERS OF MARYLAND, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/22/2015
Last Update Date: 01/29/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

116 WESTMINSTER PIKE SUITE 106
REISTERSTOWN MD
21136-1027
US

IV. Provider business mailing address

116 WESTMINSTER PIKE SUITE 106
REISTERSTOWN MD
21136-1027
US

V. Phone/Fax

Practice location:
  • Phone: 410-833-1011
  • Fax: 410-833-1680
Mailing address:
  • Phone: 410-833-1011
  • Fax: 410-833-1680

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081P2900X
TaxonomyPain Medicine (Physical Medicine & Rehabilitation) Physician
License Number
License Number State

VIII. Authorized Official

Name: TATYANA REZNIKOV
Title or Position: MBR
Credential: MD
Phone: 410-833-1101