Provider Demographics
NPI:1932934353
Name:GARRETT ANESTHESIA AND PAIN MANAGEMENT
Entity type:Organization
Organization Name:GARRETT ANESTHESIA AND PAIN MANAGEMENT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MELVIN
Authorized Official - Middle Name:R
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 STE 3
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 1:4 S BROADWAY
Practice Address - Street 2:
Practice Address - City:FROSTBURG
Practice Address - State:MD
Practice Address - Zip Code:21532-1708
Practice Address - Country:US
Practice Address - Phone:301-689-3138
Practice Address - Fax:301-689-9561
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GARRETT ANESTHESIA AND PAIN MANAGEMENT
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2024-09-05
Last Update Date:2024-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD654131301Medicaid