Provider Demographics
NPI:1104276211
Name:GARRETT ANESTHESIA AND PAIN MANAGEMENT
Entity type:Organization
Organization Name:GARRETT ANESTHESIA AND PAIN MANAGEMENT
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MELVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:GONZAGA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:240-362-7128
Mailing Address - Street 1:957 NATIONAL HWY
Mailing Address - Street 2:
Mailing Address - City:LAVALE
Mailing Address - State:MD
Mailing Address - Zip Code:21502-7356
Mailing Address - Country:US
Mailing Address - Phone:240-362-7128
Mailing Address - Fax:240-362-7129
Practice Address - Street 1:957 NATIONAL HWY
Practice Address - Street 2:
Practice Address - City:LAVALE
Practice Address - State:MD
Practice Address - Zip Code:21502-7356
Practice Address - Country:US
Practice Address - Phone:240-362-7718
Practice Address - Fax:240-362-7731
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GARRETT ANESTHESIA AND PAIN MANAGEMENT
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-06-20
Last Update Date:2016-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD24488225100000X
WV07532225X00000X
MD07755235Z00000X
MDD0022148208VP0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain MedicineGroup - Multi-Specialty
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
No235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty