Provider Demographics
NPI:1457784852
Name:SMART PAIN SURGERY CENTER AT OWINGS MILLS, LLC
Entity type:Organization
Organization Name:SMART PAIN SURGERY CENTER AT OWINGS MILLS, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:IRA
Authorized Official - Middle Name:
Authorized Official - Last Name:KORNBLUTH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:855-527-7246
Mailing Address - Street 1:201 DEFENSE HWY STE 205
Mailing Address - Street 2:
Mailing Address - City:ANNAPOLIS
Mailing Address - State:MD
Mailing Address - Zip Code:21401-7096
Mailing Address - Country:US
Mailing Address - Phone:855-527-7246
Mailing Address - Fax:866-229-5063
Practice Address - Street 1:9 PARK CENTER CT.
Practice Address - Street 2:SUITE 100
Practice Address - City:OWINGS MILLS
Practice Address - State:MD
Practice Address - Zip Code:21117
Practice Address - Country:US
Practice Address - Phone:410-205-7667
Practice Address - Fax:410-205-7274
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-08-21
Last Update Date:2024-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0061293261QA1903X
MDA1555261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD422785900Medicaid
MD347179OtherMEDICARE