Provider Demographics
NPI:1356619803
Name:MARYLAND INTERVENTIONAL PAIN MANAGEMENT LLC
Entity type:Organization
Organization Name:MARYLAND INTERVENTIONAL PAIN MANAGEMENT LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADM
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:
Authorized Official - Last Name:MARTELLONI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:865-466-0650
Mailing Address - Street 1:5430 CAMPBELL BLVD
Mailing Address - Street 2:SUITE 106
Mailing Address - City:WHITE MARSH
Mailing Address - State:MD
Mailing Address - Zip Code:21162-5500
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5430 CAMPBELL BLVD
Practice Address - Street 2:SUITE 106
Practice Address - City:WHITE MARSH
Practice Address - State:MD
Practice Address - Zip Code:21162-5500
Practice Address - Country:US
Practice Address - Phone:443-725-4930
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-12
Last Update Date:2011-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain MedicineGroup - Multi-Specialty