Provider Demographics
NPI:1346708492
Name:PROVIDENCE PAIN MANAGEMENT CENTER, PA
Entity Type:Organization
Organization Name:PROVIDENCE PAIN MANAGEMENT CENTER, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:AKARA
Authorized Official - Middle Name:
Authorized Official - Last Name:FORSYTHE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:301-750-9500
Mailing Address - Street 1:6911 LAUREL BOWIE RD
Mailing Address - Street 2:SUITE 212
Mailing Address - City:BOWIE
Mailing Address - State:MD
Mailing Address - Zip Code:20721
Mailing Address - Country:US
Mailing Address - Phone:301-750-9500
Mailing Address - Fax:
Practice Address - Street 1:14201 LAUREL PARK DR
Practice Address - Street 2:SUITE 223
Practice Address - City:LAUREL
Practice Address - State:MD
Practice Address - Zip Code:20707
Practice Address - Country:US
Practice Address - Phone:301-798-9300
Practice Address - Fax:301-355-2101
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PROVIDENCE PAIN MANAGEMENT CENTER, PA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-03-07
Last Update Date:2019-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain MedicineGroup - Multi-Specialty