Healthcare Provider Details

I. General information

NPI: 1770868903
Provider Name (Legal Business Name): SPINE MEDICINE AND REHAB
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/19/2011
Last Update Date: 10/19/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

826 WASHINGTON RD SUITE 112
WESTMINSTER MD
21157
US

IV. Provider business mailing address

826 WASHINGTON RD SUITE 210
WESTMINSTER MD
21157-5750
US

V. Phone/Fax

Practice location:
  • Phone: 443-605-0500
  • Fax: 866-605-3654
Mailing address:
  • Phone: 443-605-0500
  • Fax: 866-605-3654

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number StateMD

VIII. Authorized Official

Name: DR. IRA D KORNBLUTH
Title or Position: OWNER
Credential:
Phone: 443-605-0500