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General NPI Number Information
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NPI Number | 1285121749
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Entity Type | Organization
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Legal Business Name | PROVIDENCE PAIN MANAGEMENT CENTER, P.A.
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Dates
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Enumeration Date | 04/19/2018
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Last Update Date | 08/13/2019
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Provider Practice Location Address
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Address Line | 6911 LAUREL BOWIE RD STE 212B
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City | BOWIE
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State | MD
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Zip | 20715-1712
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Country | US
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Telephone | 301-755-9500
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Fax | 301-747-6017
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Provider Business Mailing Address
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Address Line | 6911 LAUREL BOWIE RD STE 212B
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City | BOWIE
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State | MD
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Zip | 20715-1712
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Country | US
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Telephone | 301-755-9500
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Fax | 301-747-6017
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Authorized Official
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Title or Position | CEO
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Name | JOSEPH MAXWELL OPPONG
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Credential | M.D.
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Telephone | 301-750-9500
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 291U00000X
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Taxonomy Name | Clinical Medical Laboratory
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License Number | 21D2142104
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License Number State | MD
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