Provider Demographics
NPI:1255695490
Name:ADVANCED SPINE AND PAIN PLLC
Entity type:Organization
Organization Name:ADVANCED SPINE AND PAIN PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:
Authorized Official - Last Name:RALEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:703-522-2727
Mailing Address - Street 1:PO BOX 62234
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21264-2234
Mailing Address - Country:US
Mailing Address - Phone:703-522-2727
Mailing Address - Fax:
Practice Address - Street 1:2046 JEFFERSON DAVIS HWY
Practice Address - Street 2:103
Practice Address - City:STAFFORD
Practice Address - State:VA
Practice Address - Zip Code:22554-7276
Practice Address - Country:US
Practice Address - Phone:703-522-2727
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-03
Last Update Date:2012-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101243103207XS0117X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207XS0117XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Surgery of the SpineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VADQ1510OtherRRCARE
VA172648Medicare PIN
VAC10992Medicare PIN