Provider Demographics
NPI:1003283938
Name:MID ATLANTIC PAIN MANAGEMENT, LLC
Entity Type:Organization
Organization Name:MID ATLANTIC PAIN MANAGEMENT, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COO
Authorized Official - Prefix:
Authorized Official - First Name:LEWIE
Authorized Official - Middle Name:G
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:301-829-7683
Mailing Address - Street 1:1302 RISING RIDGE RD
Mailing Address - Street 2:SUITE 1
Mailing Address - City:MOUNT AIRY
Mailing Address - State:MD
Mailing Address - Zip Code:21771-5790
Mailing Address - Country:US
Mailing Address - Phone:301-829-7683
Mailing Address - Fax:301-829-7694
Practice Address - Street 1:3930 PENDER DR
Practice Address - Street 2:SUITE 120
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22030-0985
Practice Address - Country:US
Practice Address - Phone:301-829-7693
Practice Address - Fax:301-829-7694
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-08-26
Last Update Date:2015-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain MedicineGroup - Multi-Specialty
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
0352193OtherAETNA HMO
VA1861818270Medicaid
BE66OtherCAREFIRST BCBS
DV0457OtherRAILROAD MEDICARE
5395974OtherAETNA NON-HMO
618183700OtherUSDOL OWCP
BE66OtherCAREFIRST BCBS