MEDICARE: ADVANTIA HEALTH SPINE-SPORTS & PAIN CENTER OF MARYLAND LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207LP2900X	Pain Medicine (Anesthesiology) Physician

General Provider Information

NPI Number	:	1629447453
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ADVANTIA HEALTH SPINE-SPORTS & PAIN CENTER OF MARYLAND LLC

Provider Business Mailing Address
First Line	:	1400 FOREST GLEN RD STE 500
Second Line	:
City	:	SILVER SPRING
State	:	MD
Zip	:	20910-1467
Country	:	US
Telephone Number	:	301-453-5970
Fax Number	:

Provider Business Practice Location Address
First Line	:	12240 INDIAN CREEK CT
Second Line	:	SUITE 130A
City	:	BELTSVILLE
State	:	MD
Zip	:	20705-1242
Country	:	US
Telephone Number	:	571-327-1334
Fax Number	:	240-264-8436

Authorized Official
Title or Position	:	CMO
Name	:	DR. PETER GLASS
Credential	:	MD
Telephone Number	:	301-453-5970

Provider Enumeration Date	:	09/22/2015
Last Update Date	:	07/21/2022

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