Provider Demographics
NPI:1164796181
Name:ANNAPOLIS BACK & NECK CENTER, LLC
Entity Type:Organization
Organization Name:ANNAPOLIS BACK & NECK CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:WAGNER
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:410-267-0033
Mailing Address - Street 1:914 BAY RIDGE RD STE 150
Mailing Address - Street 2:
Mailing Address - City:ANNAPOLIS
Mailing Address - State:MD
Mailing Address - Zip Code:21403-3953
Mailing Address - Country:US
Mailing Address - Phone:410-267-0033
Mailing Address - Fax:410-267-0444
Practice Address - Street 1:914 BAY RIDGE RD STE 150
Practice Address - Street 2:
Practice Address - City:ANNAPOLIS
Practice Address - State:MD
Practice Address - Zip Code:21403-3953
Practice Address - Country:US
Practice Address - Phone:410-267-0033
Practice Address - Fax:410-267-0444
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-08
Last Update Date:2012-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDS01457111NS0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NS0005XChiropractic ProvidersChiropractorSports PhysicianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDM155OtherBCBS
MDW2090001OtherBCBS FEP
MDW2090001OtherBCBS FEP
MDM155OtherBCBS