Provider Demographics
NPI:1093995607
Name:NORTHERN VIRGINIA PAIN MANAGEMENT ASSOCIATES, LLC
Entity Type:Organization
Organization Name:NORTHERN VIRGINIA PAIN MANAGEMENT ASSOCIATES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:CORELLA
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:FENWICK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:301-668-4842
Mailing Address - Street 1:141 THOMAS JOHNSON DR
Mailing Address - Street 2:SUITE 190
Mailing Address - City:FREDERICK
Mailing Address - State:MD
Mailing Address - Zip Code:21702-4502
Mailing Address - Country:US
Mailing Address - Phone:301-668-4403
Mailing Address - Fax:301-668-4406
Practice Address - Street 1:124 PARK ST SE
Practice Address - Street 2:SUITE 203
Practice Address - City:VIENNA
Practice Address - State:VA
Practice Address - Zip Code:22180-4654
Practice Address - Country:US
Practice Address - Phone:703-319-1006
Practice Address - Fax:703-319-1008
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-12
Last Update Date:2007-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VAPENDING208VP0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain MedicineGroup - Single Specialty