Provider Demographics
NPI:1053670430
Name:MARYLAND INTERVENTIONAL PAIN MANAGEMENT, LLC
Entity Type:Organization
Organization Name:MARYLAND INTERVENTIONAL PAIN MANAGEMENT, LLC
Other - Org Name:BALTIMORE PAIN RELIEF CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:J
Authorized Official - Last Name:GOBER
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:443-725-4930
Mailing Address - Street 1:5430 CAMPBELL BLVD
Mailing Address - Street 2:SUITE 106
Mailing Address - City:WHITE MARSH
Mailing Address - State:MD
Mailing Address - Zip Code:21162-5500
Mailing Address - Country:US
Mailing Address - Phone:443-725-4930
Mailing Address - Fax:443-725-4933
Practice Address - Street 1:1147 S HANOVER ST
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21230-3717
Practice Address - Country:US
Practice Address - Phone:443-725-4930
Practice Address - Fax:443-725-4933
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MARYLAND INTERVENTIONAL PAIN MANAGEMENT, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-05-07
Last Update Date:2012-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD3470111N00000X
MD60828208D00000X
MD3825363A00000X
MD3868363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
No111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty