Provider Demographics
NPI:1174884258
Name:PAIN AND SPINE SPECIALISTS OF MARYLAND, LLC
Entity type:Organization
Organization Name:PAIN AND SPINE SPECIALISTS OF MARYLAND, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:SUDHIR
Authorized Official - Middle Name:
Authorized Official - Last Name:RAO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:310-703-8767
Mailing Address - Street 1:2702 BACK ACRE CIRCLE
Mailing Address - Street 2:290B
Mailing Address - City:MOUNT AIRY
Mailing Address - State:MD
Mailing Address - Zip Code:21771-7769
Mailing Address - Country:US
Mailing Address - Phone:301-703-8767
Mailing Address - Fax:301-703-8766
Practice Address - Street 1:2702 BACK ARCE CIRCLE
Practice Address - Street 2:290B
Practice Address - City:MOUNT AIRY
Practice Address - State:MD
Practice Address - Zip Code:21771-7769
Practice Address - Country:US
Practice Address - Phone:301-703-8767
Practice Address - Fax:301-703-8766
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-06-05
Last Update Date:2023-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
208VP0000X, 208VP0014X, 363LP0808X, 207LP2900X, 101YA0400X, 103TC0700X, 101YP2500X, 103TA0400X, 101Y00000X
MD174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Multi-Specialty
No208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain MedicineGroup - Multi-Specialty
No208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain MedicineGroup - Multi-Specialty
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Multi-Specialty
No207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain MedicineGroup - Multi-Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No103TA0400XBehavioral Health & Social Service ProvidersPsychologistAddiction (Substance Use Disorder)Group - Multi-Specialty
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty