Provider Demographics
NPI:1124302690
Name:SUMMIT PAIN MANAGEMENT GROUP,INC
Entity type:Organization
Organization Name:SUMMIT PAIN MANAGEMENT GROUP,INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT AND C.E.O.
Authorized Official - Prefix:DR
Authorized Official - First Name:OLAKUNLE
Authorized Official - Middle Name:
Authorized Official - Last Name:TAIWO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:301-996-9354
Mailing Address - Street 1:8056 IANS ALY
Mailing Address - Street 2:
Mailing Address - City:LAUREL
Mailing Address - State:MD
Mailing Address - Zip Code:20724-6133
Mailing Address - Country:US
Mailing Address - Phone:301-996-9354
Mailing Address - Fax:
Practice Address - Street 1:603 REVOLUTION ST
Practice Address - Street 2:
Practice Address - City:HAVRE DE GRACE
Practice Address - State:MD
Practice Address - Zip Code:21078-3319
Practice Address - Country:US
Practice Address - Phone:410-942-1015
Practice Address - Fax:410-942-1016
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-03
Last Update Date:2011-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0050806251B00000X, 261Q00000X, 207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain MedicineGroup - Single Specialty
No251B00000XAgenciesCase ManagementGroup - Single Specialty
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0017816740003Medicaid
056023Medicare PIN
PA05623Medicare PIN
PAG86842Medicare UPIN