Provider Demographics
NPI:1407184872
Name:ATLANTIC INTERVENTIONAL PAIN MANAGEMENT
Entity Type:Organization
Organization Name:ATLANTIC INTERVENTIONAL PAIN MANAGEMENT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:HADDIJATOU
Authorized Official - Middle Name:SECKA
Authorized Official - Last Name:OGUNSOLA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:410-382-3013
Mailing Address - Street 1:1424 ILLINOIS AVE
Mailing Address - Street 2:
Mailing Address - City:SEVERN
Mailing Address - State:MD
Mailing Address - Zip Code:21144-2643
Mailing Address - Country:US
Mailing Address - Phone:410-382-3013
Mailing Address - Fax:410-590-8839
Practice Address - Street 1:8109 RITCHIE HWY
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:MD
Practice Address - Zip Code:21122-6917
Practice Address - Country:US
Practice Address - Phone:410-382-3013
Practice Address - Fax:410-590-8839
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-11-24
Last Update Date:2010-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDPENDINGOtherMEDICAL ASSISTANCE
MDPENDINGOtherCAREFIRST
DCPENDINGOtherCAREFIRST
MD170685OtherMEDICARE
GAPENDINGOtherRAILROAD MEDICARE