Healthcare Provider Details

I. General information

NPI: 1124764220
Provider Name (Legal Business Name): ADVANCED SPINE AND PAIN CENTERS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/11/2022
Last Update Date: 05/11/2022
Certification Date: 05/11/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

450 GARRISONVILLE RD STE 109
STAFFORD VA
22554-1615
US

IV. Provider business mailing address

217 E CHURCHVILLE RD
BEL AIR MD
21014-3825
US

V. Phone/Fax

Practice location:
  • Phone: 703-522-2727
  • Fax: 703-542-3753
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: BRIAN LEE
Title or Position: OWNER
Credential: MD
Phone: 240-988-1227