Provider Demographics
NPI:1992856025
Name:CARROLL COUNTY MSO INC
Entity type:Organization
Organization Name:CARROLL COUNTY MSO INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:VAJIRA
Authorized Official - Middle Name:
Authorized Official - Last Name:GUNAWARDANE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:410-871-6139
Mailing Address - Street 1:291 STONER AVE
Mailing Address - Street 2:
Mailing Address - City:WESTMINSTER
Mailing Address - State:MD
Mailing Address - Zip Code:21157-5647
Mailing Address - Country:US
Mailing Address - Phone:410-871-6139
Mailing Address - Fax:410-871-6112
Practice Address - Street 1:208 E RIDGEVILLE BLVD
Practice Address - Street 2:201
Practice Address - City:MOUNT AIRY
Practice Address - State:MD
Practice Address - Zip Code:21771-5219
Practice Address - Country:US
Practice Address - Phone:301-829-7683
Practice Address - Fax:301-829-7694
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-16
Last Update Date:2007-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0047120207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA031LMedicare PIN