Provider Demographics
NPI:1225459936
Name:CENTER FOR SPORTS AND REGENERATIVE ORTHOPEDICS, LLC
Entity Type:Organization
Organization Name:CENTER FOR SPORTS AND REGENERATIVE ORTHOPEDICS, LLC
Other - Org Name:PAIN AND WELLNESS CENTER OF MARYLAND, LLC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:MIRIAM
Authorized Official - Middle Name:
Authorized Official - Last Name:RAZAQ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:240-754-7954
Mailing Address - Street 1:601 POST OFFICE RD STE 2A
Mailing Address - Street 2:
Mailing Address - City:WALDORF
Mailing Address - State:MD
Mailing Address - Zip Code:20602-1912
Mailing Address - Country:US
Mailing Address - Phone:240-754-7954
Mailing Address - Fax:240-754-7958
Practice Address - Street 1:601 POST OFFICE RD STE 2A
Practice Address - Street 2:
Practice Address - City:WALDORF
Practice Address - State:MD
Practice Address - Zip Code:20602
Practice Address - Country:US
Practice Address - Phone:240-754-7954
Practice Address - Fax:240-754-7958
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-12-23
Last Update Date:2022-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDH673402081P2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD589609600Medicaid