Provider Demographics
NPI:1629447453
Name:ADVANTIA HEALTH SPINE-SPORTS & PAIN CENTER OF MARYLAND LLC
Entity Type:Organization
Organization Name:ADVANTIA HEALTH SPINE-SPORTS & PAIN CENTER OF MARYLAND LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CMO
Authorized Official - Prefix:DR
Authorized Official - First Name:PETER
Authorized Official - Middle Name:
Authorized Official - Last Name:GLASS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:301-453-5970
Mailing Address - Street 1:1400 FOREST GLEN RD STE 500
Mailing Address - Street 2:
Mailing Address - City:SILVER SPRING
Mailing Address - State:MD
Mailing Address - Zip Code:20910-1467
Mailing Address - Country:US
Mailing Address - Phone:301-453-5970
Mailing Address - Fax:
Practice Address - Street 1:12240 INDIAN CREEK CT
Practice Address - Street 2:SUITE 130A
Practice Address - City:BELTSVILLE
Practice Address - State:MD
Practice Address - Zip Code:20705-1242
Practice Address - Country:US
Practice Address - Phone:571-327-1334
Practice Address - Fax:240-264-8436
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ADVANTIA HOLDINGS OF MARYLAND LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-09-22
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain MedicineGroup - Single Specialty