1053327874 NPI number — JCB ANESTHESIA & PAIN MANAGEMENT, PC

Table of content: (NPI 1053327874)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053327874 NPI number — JCB ANESTHESIA & PAIN MANAGEMENT, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JCB ANESTHESIA & PAIN MANAGEMENT, PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
COMPREHENSIVE PAIN CLINIC AND WELLNESS CENTER
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1053327874
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/30/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 700908
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DALLAS
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75370-0908
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
972-212-5858
Provider Business Mailing Address Fax Number:
214-291-5635

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
600 EAST BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ELKHART
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46514-2483
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
574-523-3103
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/01/2006

Additional Information

Authorized Official

Authorized Official Last Name:
CHAO
Authorized Official First Name:
JULIE
Authorized Official Middle Name:
YIA-PEI
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
260-312-2489

Provider Taxonomy Codes

  • Taxonomy code: 207LP2900X , with the licence number:  50003982A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208VP0000X , with the licence number: 50003982A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: DR2350 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 100376480B , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 201012780A , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".




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