=====================================================
General NPI Number Information
=====================================================
NPI Number | 1548084940
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SYNERGY PC VA LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/12/2024
-----------------------------------------------------
Last Update Date | 11/12/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6513 BAYTHORNE RD
-----------------------------------------------------
City | BALTIMORE
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21209-2637
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 443-929-0404
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6513 BAYTHORNE RD
-----------------------------------------------------
City | BALTIMORE
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21209-2637
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 443-929-0404
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | TRUSTEE
-----------------------------------------------------
Name | DAVID STEINBERG
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 443-929-0404
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2081P2900X
-----------------------------------------------------
Taxonomy Name | Pain Medicine (Physical Medicine & Rehabilitation) Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 208600000X
-----------------------------------------------------
Taxonomy Name | Surgery Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 207RG0300X
-----------------------------------------------------
Taxonomy Name | Geriatric Medicine (Internal Medicine) Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 207RI0200X
-----------------------------------------------------
Taxonomy Name | Infectious Disease Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #5
-----------------------------------------------------
Taxonomy Code | 363LP2300X
-----------------------------------------------------
Taxonomy Name | Primary Care Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------