Basic Information
| Provider Information | |||||||||
| NPI: | 1952739203 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NEWBRIDGE SPINE AND PAIN CENTER OF VIRGINIA LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 196 THOMAS JOHNSON DR | ||||||||
| Address2: | SUITE 215 | ||||||||
| City: | FREDERICK | ||||||||
| State: | MD | ||||||||
| PostalCode: | 217024397 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3016689988 | ||||||||
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| Practice Location | |||||||||
| Address1: | 161 FORT EVANS RD NE | ||||||||
| Address2: | SUITE 340 | ||||||||
| City: | LEESBURG | ||||||||
| State: | VA | ||||||||
| PostalCode: | 201763369 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7034438000 | ||||||||
| FaxNumber: | 7034438100 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/24/2013 | ||||||||
| LastUpdateDate: | 06/16/2014 | ||||||||
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| AuthorizedOfficialLastName: | GONCHIGAR | ||||||||
| AuthorizedOfficialFirstName: | MRUTHYUNJAYA | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER/PHYSICIAN | ||||||||
| AuthorizedOfficialTelephone: | 3016689988 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |
No ID Information.