1558583732 NPI number — PIASA PAIN CENTER LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1558583732 NPI number — PIASA PAIN CENTER LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PIASA PAIN CENTER LLC
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:
Provider Other Organization Name Type Code:
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:
1558583732
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
940 WEST PORT PLAZA
Provider Second Line Business Mailing Address:
STE 270
Provider Business Mailing Address City Name:
ST LOUIS
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
63146-3118
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
314-453-0600
Provider Business Mailing Address Fax Number:
314-453-0083

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
#3 PROFESSIONAL DRIVE
Provider Second Line Business Practice Location Address:
SUITE B
Provider Business Practice Location Address City Name:
ACTON
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
62002
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
618-465-7177
Provider Business Practice Location Address Fax Number:
618-465-7176
Provider Enumeration Date:
05/03/2007

Additional Information

Authorized Official

Authorized Official Last Name:
BRUMMETT
Authorized Official First Name:
THOMAS
Authorized Official Middle Name:
B
Authorized Official Title or Position:
MANAGING MEMBER
Authorized Official Telephone Number:
618-465-7177

Provider Taxonomy Codes

  • Taxonomy code: 261QP3300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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