Basic Information
Provider Information
NPI: 1093236226
EntityType: 2
ReplacementNPI:  
OrganizationName: PHYSICAL MEDICINE ASSOCIATES LTD
LastName:  
FirstName:  
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential:  
OtherOrganizationName: NATIONAL SPINE AND PAIN CENTERS
OtherOrganizationType: 3
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 11350 MCCORMICK ROAD
Address2: EXECUTIVE PLAZA 1, SUITE 501
City: HUNT VALLEY
State: MD
PostalCode: 21031
CountryCode: US
TelephoneNumber: 4103291070
FaxNumber: 4103291054
Practice Location
Address1: 3620 JOSEPH SIEWICK DR STE 101
Address2:  
City: FAIRFAX
State: VA
PostalCode: 220331757
CountryCode: US
TelephoneNumber: 7039148000
FaxNumber: 7036421876
Other Information
ProviderEnumerationDate: 06/28/2017
LastUpdateDate: 04/08/2020
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode:  
AuthorizedOfficialLastName: FRIEDLIS
AuthorizedOfficialFirstName: MAYO
AuthorizedOfficialMiddleName: F
AuthorizedOfficialTitleorPosition: PRESIDENT
AuthorizedOfficialTelephone: 7039148000
IsSoleProprietor:  
IsOrganizationSubpart: N
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix: DR.
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential: MD
NPICertificationDate: 04/08/2020

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
207LP2900X  N193200000X MULTI-SPECIALTY GROUPAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
2081P2900X  Y193200000X MULTI-SPECIALTY GROUPAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain Medicine

No ID Information.


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