Basic Information
Provider Information | |||||||||
NPI: | 1659752426 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | ROSEN-HOFFBERG REHABILITATION AND PAIN MANAGEMENT ASSOCIATES, P.A | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 8415 BELLONA LN | ||||||||
Address2: | SUITE 201 | ||||||||
City: | BALTIMORE | ||||||||
State: | MD | ||||||||
PostalCode: | 212042055 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4108217775 | ||||||||
FaxNumber: | 4108211320 | ||||||||
Practice Location | |||||||||
Address1: | 10085 RED RUN BLVD | ||||||||
Address2: | SUITE 404 | ||||||||
City: | OWINGS MILLS | ||||||||
State: | MD | ||||||||
PostalCode: | 211174836 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4103637246 | ||||||||
FaxNumber: | 4103630165 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/17/2015 | ||||||||
LastUpdateDate: | 06/17/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | PASQUA | ||||||||
AuthorizedOfficialFirstName: | DONNA | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | OFFICE MANAGER | ||||||||
AuthorizedOfficialTelephone: | 4108217775 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | ROSEN-HOFFBERG REHABILITATION AND PAIN MANAGEMENT ASSOCIATES, P.A | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
ID | Type | State | Issuer | Description | 407861600 | 05 | MD |   | MEDICAID |