=====================================================
General NPI Number Information
=====================================================
NPI Number | 1811784911
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GREATER MARYLAND PAIN MANAGEMENT, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/22/2025
-----------------------------------------------------
Last Update Date | 04/22/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 110 HOSPITAL RD STE 214
-----------------------------------------------------
City | PRINCE FREDERICK
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 20678-4040
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 410-672-2555
-----------------------------------------------------
Fax | 410-816-9472
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1130 ANNAPOLIS RD STE 100
-----------------------------------------------------
City | ODENTON
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21113-1622
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 410-672-2255
-----------------------------------------------------
Fax | 410-816-9472
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | BILLING MANAGER
-----------------------------------------------------
Name | SHAWNTE MCINTOSH
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 410-672-2255
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207LP2900X
-----------------------------------------------------
Taxonomy Name | Pain Medicine (Anesthesiology) Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------