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General NPI Number Information
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NPI Number | 1861628521
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Entity Type | Organization
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Legal Business Name | PENINSULA PAIN MANAGEMENT, LLC
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Dates
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Enumeration Date | 06/08/2009
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Last Update Date | 12/08/2012
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Provider Practice Location Address
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Address Line | 13014 RIGGIN RIDGE RD
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City | OCEAN CITY
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State | MD
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Zip | 21842-9716
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Country | US
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Telephone | 443-783-3543
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Fax |
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Provider Business Mailing Address
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Address Line | 13014 RIGGIN RIDGE RD
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City | OCEAN CITY
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State | MD
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Zip | 21842-9716
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Country | US
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Telephone | 443-783-3543
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | BRENT FOX
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Credential |
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Telephone | 443-783-3543
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207N00000X
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Taxonomy Name | Dermatology Physician
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 363L00000X
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Taxonomy Name | Nurse Practitioner
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License Number |
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License Number State |
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Taxonomy #4
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Taxonomy Code | 208VP0000X
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Taxonomy Name | Pain Medicine Physician
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License Number | D0035246
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License Number State | MD
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Taxonomy #5
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Taxonomy Code | 208VP0014X
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Taxonomy Name | Interventional Pain Medicine Physician
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License Number | D0035246
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License Number State | MD
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