Provider Demographics
NPI:1073608253
Name:GARRETT ANESTHESIA AND PAIN MANAGEMENT
Entity Type:Organization
Organization Name:GARRETT ANESTHESIA AND PAIN MANAGEMENT
Other - Org Name:GONZAGA INTERVENTIONAL PAIN MANAGEMENT
Other - Org Type:Doing Business As
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
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 1:957 NATIONAL HWY
Practice Address - Street 2:
Practice Address - City:LAVALE
Practice Address - State:MD
Practice Address - Zip Code:21502
Practice Address - Country:US
Practice Address - Phone:240-362-7128
Practice Address - Fax:240-362-7129
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-04
Last Update Date:2018-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD222148208VP0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD961521100Medicaid
MD712M255FMedicare ID - Type UnspecifiedINDIVIDUAL & GROUP NUMBER
MD961521100Medicaid