Healthcare Provider Details

I. General information

NPI: 1356619803
Provider Name (Legal Business Name): MARYLAND INTERVENTIONAL PAIN MANAGEMENT LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/12/2011
Last Update Date: 12/12/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5430 CAMPBELL BLVD SUITE 106
WHITE MARSH MD
21162-5500
US

IV. Provider business mailing address

5430 CAMPBELL BLVD SUITE 106
WHITE MARSH MD
21162-5500
US

V. Phone/Fax

Practice location:
  • Phone: 443-725-4930
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code2081P2900X
TaxonomyPain Medicine (Physical Medicine & Rehabilitation) Physician
License Number
License Number StateNULL

VIII. Authorized Official

Name: MARY MARTELLONI
Title or Position: PRACTICE ADM
Credential:
Phone: 865-466-0650