Provider Demographics
NPI:1285121749
Name:PROVIDENCE PAIN MANAGEMENT CENTER, P.A.
Entity type:Organization
Organization Name:PROVIDENCE PAIN MANAGEMENT CENTER, P.A.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:MAXWELL
Authorized Official - Last Name:OPPONG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:301-750-9500
Mailing Address - Street 1:6911 LAUREL BOWIE RD STE 212B
Mailing Address - Street 2:
Mailing Address - City:BOWIE
Mailing Address - State:MD
Mailing Address - Zip Code:20715-1712
Mailing Address - Country:US
Mailing Address - Phone:301-755-9500
Mailing Address - Fax:301-747-6017
Practice Address - Street 1:6911 LAUREL BOWIE RD STE 212B
Practice Address - Street 2:
Practice Address - City:BOWIE
Practice Address - State:MD
Practice Address - Zip Code:20715-1712
Practice Address - Country:US
Practice Address - Phone:301-755-9500
Practice Address - Fax:301-747-6017
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-04-19
Last Update Date:2019-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD21D2142104291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes291U00000XLaboratoriesClinical Medical LaboratoryGroup - Multi-Specialty