Basic Information
| Provider Information | |||||||||
| NPI: | 1588941629 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CSSSDWC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 17334 | ||||||||
| Address2: | |||||||||
| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212971334 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7034436717 | ||||||||
| FaxNumber: | 7034438643 | ||||||||
| Practice Location | |||||||||
| Address1: | 224D CORNWALL ST NW | ||||||||
| Address2: | SUITE 204 | ||||||||
| City: | LEESBURG | ||||||||
| State: | VA | ||||||||
| PostalCode: | 201762700 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7037771553 | ||||||||
| FaxNumber: | 7037775524 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/03/2011 | ||||||||
| LastUpdateDate: | 11/03/2011 | ||||||||
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| AuthorizedOfficialLastName: | WATTENMAKER | ||||||||
| AuthorizedOfficialFirstName: | IAN | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | DOCTOR | ||||||||
| AuthorizedOfficialTelephone: | 7037771553 | ||||||||
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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 | 207XS0117X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Orthopaedic Surgery of the Spine |
No ID Information.