Healthcare Provider Details

I. General information

NPI: 1902364052
Provider Name (Legal Business Name): PROVIDENCE PAIN MANAGEMENT CENTER, P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/07/2019
Last Update Date: 05/22/2024
Certification Date: 05/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 PINE BLUFF RD STE 1
SALISBURY MD
21801-1401
US

IV. Provider business mailing address

6911 LAUREL BOWIE RD SUITE 212
BOWIE MD
20715-1400
US

V. Phone/Fax

Practice location:
  • Phone: 410-268-2000
  • Fax:
Mailing address:
  • Phone: 301-750-9500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: JOSEPH OPPONG JR.
Title or Position: PRESIDENT/DIRECTOR
Credential: M.D.
Phone: 301-755-9500