Basic Information
| Provider Information | |||||||||
| NPI: | 1760872410 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PHYSICAL MEDICINE ASSOCIATES, LTD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11350 MCCORMICK ROAD | ||||||||
| Address2: | EXECUTIVE PLAZA 1, SUITE 501 | ||||||||
| City: | HUNT VALLEY | ||||||||
| State: | MD | ||||||||
| PostalCode: | 210311002 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4103291071 | ||||||||
| FaxNumber: | 4103291054 | ||||||||
| Practice Location | |||||||||
| Address1: | 1750 TYSONS BLVD STE 120 | ||||||||
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| City: | MC LEAN | ||||||||
| State: | VA | ||||||||
| PostalCode: | 221024227 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7037147178 | ||||||||
| FaxNumber: | 7032880214 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/03/2015 | ||||||||
| LastUpdateDate: | 10/24/2017 | ||||||||
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| AuthorizedOfficialLastName: | FRIDELIS | ||||||||
| AuthorizedOfficialFirstName: | MAYO | ||||||||
| AuthorizedOfficialMiddleName: | F | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7039148000 | ||||||||
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| 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 | 2081P2900X | VA | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | Pain Medicine |
No ID Information.