Provider Demographics
NPI:1790921450
Name:NEWBRIDGE SPINE AND PAIN CENTER LLC
Entity Type:Organization
Organization Name:NEWBRIDGE SPINE AND PAIN CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:MRUTHYUNJAYA
Authorized Official - Middle Name:
Authorized Official - Last Name:GONCHIGAR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:301-668-9988
Mailing Address - Street 1:196 THOMAS JOHNSON DR
Mailing Address - Street 2:SUITE 215
Mailing Address - City:FREDERICK
Mailing Address - State:MD
Mailing Address - Zip Code:21702-4397
Mailing Address - Country:US
Mailing Address - Phone:301-668-9988
Mailing Address - Fax:301-668-9977
Practice Address - Street 1:196 THOMAS JOHNSON DR
Practice Address - Street 2:SUITE 215
Practice Address - City:FREDERICK
Practice Address - State:MD
Practice Address - Zip Code:21702-4397
Practice Address - Country:US
Practice Address - Phone:301-668-9988
Practice Address - Fax:301-668-9977
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-31
Last Update Date:2013-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD162245Medicare PIN