Basic Information
| Provider Information | |||||||||
| NPI: | 1093995607 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NORTHERN VIRGINIA PAIN MANAGEMENT ASSOCIATES, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 141 THOMAS JOHNSON DR | ||||||||
| Address2: | SUITE 190 | ||||||||
| City: | FREDERICK | ||||||||
| State: | MD | ||||||||
| PostalCode: | 217024502 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3016684403 | ||||||||
| FaxNumber: | 3016684406 | ||||||||
| Practice Location | |||||||||
| Address1: | 124 PARK ST SE | ||||||||
| Address2: | SUITE 203 | ||||||||
| City: | VIENNA | ||||||||
| State: | VA | ||||||||
| PostalCode: | 221804654 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7033191006 | ||||||||
| FaxNumber: | 7033191008 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/12/2007 | ||||||||
| LastUpdateDate: | 11/12/2007 | ||||||||
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| AuthorizedOfficialLastName: | FENWICK | ||||||||
| AuthorizedOfficialFirstName: | CORELLA | ||||||||
| AuthorizedOfficialMiddleName: | MARIE | ||||||||
| AuthorizedOfficialTitleorPosition: | PRACTICE ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 3016684842 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208VP0000X | PENDING | VA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pain Medicine | Pain Medicine |
No ID Information.