Basic Information
| Provider Information | |||||||||
| NPI: | 1487837886 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PAIN MANAGEMENT ASSOCIATES | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3247 ELEANORS GARDEN WAY | ||||||||
| Address2: | |||||||||
| City: | WOODBINE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 217977508 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3017040681 | ||||||||
| FaxNumber: | 3018059791 | ||||||||
| Practice Location | |||||||||
| Address1: | 4000 MITCHELLVILLE RD. SUITE B 116 | ||||||||
| Address2: | |||||||||
| City: | BOWIE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 20716 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3014645575 | ||||||||
| FaxNumber: | 3018059791 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/10/2007 | ||||||||
| LastUpdateDate: | 02/08/2008 | ||||||||
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| AuthorizedOfficialLastName: | HAGOS | ||||||||
| AuthorizedOfficialFirstName: | HADDIS | ||||||||
| AuthorizedOfficialMiddleName: | T | ||||||||
| AuthorizedOfficialTitleorPosition: | PRSIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3014645575 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207LP2900X | D0059481 | MD | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology | Pain Medicine |
ID Information
| ID | Type | State | Issuer | Description | G627/0001 | 01 | BC/BS/CHOICE/FED | OTHER | 310473 | 01 | MAMSI/ALLIANCE | OTHER | 00B889P38 | 01 | MD | PROVIDER PIN NUMBER | OTHER | 0455830 | 05 | DC | MEDICAID | HMO 3214770 | 01 | AETNA US HEALTHCARE | OTHER | NON HMO 4240271 | 01 | AETNA US HEALTHCARE | OTHER |