Provider Demographics
NPI:1174917736
Name:PAIN TREATMENT CENTERS OF MARYLAND, LLC
Entity type:Organization
Organization Name:PAIN TREATMENT CENTERS OF MARYLAND, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MBR
Authorized Official - Prefix:
Authorized Official - First Name:TATYANA
Authorized Official - Middle Name:
Authorized Official - Last Name:REZNIKOV
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:410-833-1101
Mailing Address - Street 1:116 WESTMINSTER PIKE
Mailing Address - Street 2:SUITE 106
Mailing Address - City:REISTERSTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:21136-1027
Mailing Address - Country:US
Mailing Address - Phone:410-833-1011
Mailing Address - Fax:410-833-1680
Practice Address - Street 1:116 WESTMINSTER PIKE
Practice Address - Street 2:SUITE 106
Practice Address - City:REISTERSTOWN
Practice Address - State:MD
Practice Address - Zip Code:21136-1027
Practice Address - Country:US
Practice Address - Phone:410-833-1011
Practice Address - Fax:410-833-1680
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-03-22
Last Update Date:2016-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD130198OtherMEDICARE PTAN
MD512314300Medicaid