Provider Demographics
NPI:1043288376
Name:MARYLAND BRAIN SPINE & PAIN LLC
Entity Type:Organization
Organization Name:MARYLAND BRAIN SPINE & PAIN LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:J
Authorized Official - Last Name:SULLIVAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:410-266-2720
Mailing Address - Street 1:1000 BESTGATE RD STE 400
Mailing Address - Street 2:
Mailing Address - City:ANNAPOLIS
Mailing Address - State:MD
Mailing Address - Zip Code:21401-3371
Mailing Address - Country:US
Mailing Address - Phone:410-266-2720
Mailing Address - Fax:443-224-0209
Practice Address - Street 1:4201 NORTHVIEW DR STE 101
Practice Address - Street 2:
Practice Address - City:BOWIE
Practice Address - State:MD
Practice Address - Zip Code:20716-2644
Practice Address - Country:US
Practice Address - Phone:410-266-2720
Practice Address - Fax:410-224-0209
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-11
Last Update Date:2018-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
DCD380OtherBCBS
MD404557200Medicaid
MD404557201Medicaid
MD003QMAOtherBCBS
5116110001Medicare PIN
MD404557201Medicaid
MD404557200Medicaid
DH0553Medicare PIN
G01821Medicare PIN