Provider Demographics
NPI:1487837886
Name:PAIN MANAGEMENT ASSOCIATES
Entity Type:Organization
Organization Name:PAIN MANAGEMENT ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRSIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:HADDIS
Authorized Official - Middle Name:T
Authorized Official - Last Name:HAGOS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:301-464-5575
Mailing Address - Street 1:3247 ELEANORS GARDEN WAY
Mailing Address - Street 2:
Mailing Address - City:WOODBINE
Mailing Address - State:MD
Mailing Address - Zip Code:21797-7508
Mailing Address - Country:US
Mailing Address - Phone:301-704-0681
Mailing Address - Fax:301-805-9791
Practice Address - Street 1:4000 MITCHELLVILLE RD. SUITE B 116
Practice Address - Street 2:
Practice Address - City:BOWIE
Practice Address - State:MD
Practice Address - Zip Code:20716
Practice Address - Country:US
Practice Address - Phone:301-464-5575
Practice Address - Fax:301-805-9791
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-10
Last Update Date:2008-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0059481207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
G627/0001OtherBC/BS/CHOICE/FED
310473OtherMAMSI/ALLIANCE
MD00B889P38OtherPROVIDER PIN NUMBER
DC0455830Medicaid
HMO 3214770OtherAETNA US HEALTHCARE
NON HMO 4240271OtherAETNA US HEALTHCARE
G627/0001OtherBC/BS/CHOICE/FED
MDG01238Medicare PIN