Provider Demographics
NPI:1326228081
Name:SPINE MEDICINE AND REHABILITATION
Entity Type:Organization
Organization Name:SPINE MEDICINE AND REHABILITATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:IRA
Authorized Official - Middle Name:D
Authorized Official - Last Name:KORNBLUTH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:202-607-9788
Mailing Address - Street 1:826 WASHINGTON RD
Mailing Address - Street 2:SUITE 210
Mailing Address - City:WESTMINSTER
Mailing Address - State:MD
Mailing Address - Zip Code:21157-5750
Mailing Address - Country:US
Mailing Address - Phone:202-607-9788
Mailing Address - Fax:
Practice Address - Street 1:7920 MCDONOGH RD
Practice Address - Street 2:201
Practice Address - City:OWINGS MILLS
Practice Address - State:MD
Practice Address - Zip Code:21117-5273
Practice Address - Country:US
Practice Address - Phone:443-321-2590
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-11
Last Update Date:2013-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0061293208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD6444390001Medicare NSC