FAIRWOOD SPINE AND PAIN CENTER - NPI NUMBER 1235484353

Summary

Provider Name: FAIRWOOD SPINE AND PAIN CENTER

NPI Number: 1235484353

Clasification: Pain Medicine (208VP0014X)

Specialization: Interventional Pain Medicine

Address:
12200 ANNAPOLIS RD
STE 123
GLENN DALE, MD
ZIP 20769

Phone Number: (443) 875-4300



Detailed Information

FAIRWOOD SPINE AND PAIN CENTER is an interventional pain medicine physician in Glenn Dale, MD. The provider is interventional Pain Medicine is the discipline of medicine devoted to the diagnosis and treatment of pain and related disorders principally with the application of interventional techniques in managing subacute, chronic, persistent, and intractable pain, independently or in conjunction with other modalities of treatment. The assigned NPI number for this provider is 1235484353 and is registered as an organization entity type and is a multiple single specialty group.

The provider's business address is:

12200 ANNAPOLIS RD
STE 123
GLENN DALE, MD
ZIP 20769-182
Phone: (443) 875-4300

The provider's authorized official is Joseph Oppong .
The authorized official title is Co-director and has the following contact phone number (443) 875-4300.

The enumeration date for this NPI number is 7/15/2012 and was last updated on 8/20/2012.

Map - Location of Practice





Taxonomy Codes

The following information regarding the scope of practice of this provider is available:

No. Taxonomy Code Taxonomy Clasification Taxonomy Specialization License Number License State Primary
1 208VP0014X Pain Medicine Interventional Pain Medicine D0072898 MD No
2 208VP0014X Pain Medicine Interventional Pain Medicine D0066706 MD Yes

NPI Record

No. Field Name Field Value
1 NPI 1235484353
2 Entity Type Code 2
3 Employer Identification Number EIN
4 Provider Organization Name Legal Business Name FAIRWOOD SPINE AND PAIN CENTER
5 Provider First Line Business Practice Location Address 12200 ANNAPOLIS RD
6 Provider Second Line Business Practice Location Address STE 123
7 Provider Business Practice Location Address City Name GLENN DALE
8 Provider Business Practice Location Address State Name MD
9 Provider Business Practice Location Address Postal Code 207699182
10 Provider Business Practice Location Address Country Code If outside U S US
11 Provider Business Practice Location Address Telephone Number 4438754300
12 Provider Enumeration Date 7/15/2012
13 Last Update Date 8/20/2012
14 Authorized Official Last Name OPPONG
15 Authorized Official First Name JOSEPH
16 Authorized Official Title or Position CO-DIRECTOR
17 Authorized Official Telephone Number 4438754300
18 Healthcare Provider Taxonomy Code 1 208VP0014X
19 Provider License Number 1 D0072898
20 Provider License Number State Code 1 MD
21 Healthcare Provider Primary Taxonomy Switch 1 N
22 Healthcare Provider Taxonomy Code 2 208VP0014X
23 Provider License Number 2 D0066706
24 Provider License Number State Code 2 MD
25 Healthcare Provider Primary Taxonomy Switch 2 Y
26 Is Organization Subpart N
27 Authorized Official Name Suffix Text JR.
28 Authorized Official Credential Text M.D.
29 Healthcare Provider Taxonomy Group 1 193400000X MULTIPLE SINGLE SPECIALTY GROUP
30 Healthcare Provider Taxonomy Group 2 193400000X MULTIPLE SINGLE SPECIALTY GROUP

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This page was last updated on: 10/12/2014
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