Provider Demographics
NPI:1083662753
Name:CENTERS FOR REHABILITATION, PAIN MGMT, & WELLNESS
Entity Type:Organization
Organization Name:CENTERS FOR REHABILITATION, PAIN MGMT, & WELLNESS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING REPRESENTATIVE
Authorized Official - Prefix:MRS
Authorized Official - First Name:HEATHER
Authorized Official - Middle Name:A
Authorized Official - Last Name:JACONSKI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:301-953-1266
Mailing Address - Street 1:2600 LIBERTY HEIGHTS AVE.
Mailing Address - Street 2:3RD FLOOR
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21215-7804
Mailing Address - Country:US
Mailing Address - Phone:410-383-4263
Mailing Address - Fax:410-383-4005
Practice Address - Street 1:2600 LIBERTY HEIGHTS AVE.
Practice Address - Street 2:3RD FLOOR
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21215-7804
Practice Address - Country:US
Practice Address - Phone:410-383-4263
Practice Address - Fax:410-383-4005
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-05
Last Update Date:2009-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD47483174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
DO4133OtherRAILROAD MEDICARE
DO4133OtherRAILROAD MEDICARE
MD444PMedicare PIN