Provider Demographics
NPI:1932506284
Name:PROVIDENCE PAIN MANAGEMENT CENTER, P.A.
Entity Type:Organization
Organization Name:PROVIDENCE PAIN MANAGEMENT CENTER, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:
Authorized Official - Last Name:OPPONG
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:301-755-9500
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:20715-1712
Mailing Address - Country:US
Mailing Address - Phone:301-755-9500
Mailing Address - Fax:301-747-6017
Practice Address - Street 1:6911 LAUREL BOWIE RD
Practice Address - Street 2:SUITE 212
Practice Address - City:BOWIE
Practice Address - State:MD
Practice Address - Zip Code:20715-1712
Practice Address - Country:US
Practice Address - Phone:301-755-9500
Practice Address - Fax:301-747-6017
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-12-02
Last Update Date:2019-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0066706207LP2900X, 208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain MedicineGroup - Single Specialty
No207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain MedicineGroup - Single Specialty