Basic Information
Provider Information | |||||||||
NPI: | 1821338559 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | PHYSICAL MEDICINE ASSOCIATES LTD | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | NATIONAL SPINE & PAIN CENTERS | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 3031 JAVIER RD | ||||||||
Address2: | SUITE 210 | ||||||||
City: | FAIRFAX | ||||||||
State: | VA | ||||||||
PostalCode: | 220314637 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7039148000 | ||||||||
FaxNumber: | 7036421876 | ||||||||
Practice Location | |||||||||
Address1: | 3803 FAIRFAX DR | ||||||||
Address2: | SUITE 400 | ||||||||
City: | ARLINGTON | ||||||||
State: | VA | ||||||||
PostalCode: | 222035860 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7037384380 | ||||||||
FaxNumber: | 7036421876 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/16/2013 | ||||||||
LastUpdateDate: | 02/16/2013 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | FRIEDLIS | ||||||||
AuthorizedOfficialFirstName: | MAYO | ||||||||
AuthorizedOfficialMiddleName: | F | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 7039148000 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | MD | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208VP0000X |   |   | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pain Medicine | Pain Medicine |
No ID Information.