Basic Information
| Provider Information | |||||||||
| NPI: | 1043288376 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MARYLAND BRAIN SPINE & PAIN LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 1000 BESTGATE RD STE 400 | ||||||||
| Address2: | |||||||||
| City: | ANNAPOLIS | ||||||||
| State: | MD | ||||||||
| PostalCode: | 214013371 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4102662720 | ||||||||
| FaxNumber: | 4432240209 | ||||||||
| Practice Location | |||||||||
| Address1: | 4201 NORTHVIEW DR STE 101 | ||||||||
| Address2: | |||||||||
| City: | BOWIE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 207162644 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4102662720 | ||||||||
| FaxNumber: | 4102240209 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/11/2006 | ||||||||
| LastUpdateDate: | 11/29/2018 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | SULLIVAN | ||||||||
| AuthorizedOfficialFirstName: | BRIAN | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT/PHYSICIAN | ||||||||
| AuthorizedOfficialTelephone: | 4102662720 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207T00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Neurological Surgery |
ID Information
| ID | Type | State | Issuer | Description | D380 | 01 | DC | BCBS | OTHER | 404557200 | 05 | MD | MEDICAID | 404557201 | 05 | MD | MEDICAID | 003QMA | 01 | MD | BCBS | OTHER |