Provider Demographics
NPI:1265683460
Name:MARYLAND PAIN AND SPINE CENTER, L.L.C.
Entity type:Organization
Organization Name:MARYLAND PAIN AND SPINE CENTER, L.L.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:VAJIRA
Authorized Official - Middle Name:RATHNIN
Authorized Official - Last Name:GUNAWARDANE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:703-994-6655
Mailing Address - Street 1:7625 MAPLE LAWN BLVD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:FULTON
Mailing Address - State:MD
Mailing Address - Zip Code:20759-2561
Mailing Address - Country:US
Mailing Address - Phone:703-994-6655
Mailing Address - Fax:410-730-2812
Practice Address - Street 1:7625 MAPLE LAWN BLVD
Practice Address - Street 2:SUITE 100
Practice Address - City:FULTON
Practice Address - State:MD
Practice Address - Zip Code:20759-2561
Practice Address - Country:US
Practice Address - Phone:703-994-6655
Practice Address - Fax:410-730-2812
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-06
Last Update Date:2009-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0047120208VP0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD272541000Medicaid
MD272541000Medicaid