Provider Demographics
NPI:1396929816
Name:PHYSICAL MEDICINE - REHABILITATION AND PAIN MANAGEMENT
Entity type:Organization
Organization Name:PHYSICAL MEDICINE - REHABILITATION AND PAIN MANAGEMENT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ANA
Authorized Official - Middle Name:
Authorized Official - Last Name:ACEVEDO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:410-793-0791
Mailing Address - Street 1:PO BOX 2763
Mailing Address - Street 2:
Mailing Address - City:KENSINGTON
Mailing Address - State:MD
Mailing Address - Zip Code:20891-2763
Mailing Address - Country:US
Mailing Address - Phone:410-793-0791
Mailing Address - Fax:
Practice Address - Street 1:11119 ROCKVILLE PIKE
Practice Address - Street 2:STE. 200
Practice Address - City:ROCKVILLE
Practice Address - State:MD
Practice Address - Zip Code:20852-3143
Practice Address - Country:US
Practice Address - Phone:301-468-0006
Practice Address - Fax:301-468-0046
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-19
Last Update Date:2008-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
DCG02807Medicare PIN