1568958171 NPI number — FMR INTERVENTIONAL QUALITY PAIN MANAGEMENT, A PROFESSIONAL CORP

Table of content: (NPI 1568958171)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1568958171 NPI number — FMR INTERVENTIONAL QUALITY PAIN MANAGEMENT, A PROFESSIONAL CORP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FMR INTERVENTIONAL QUALITY PAIN MANAGEMENT, A PROFESSIONAL CORP
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:
FMR INTERVENTIONAL QPM
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:
1568958171
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/28/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
12415 NORWALK BLVD
Provider Second Line Business Mailing Address:
UNIT 59600
Provider Business Mailing Address City Name:
NORWALK
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
90652
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
310-294-9027
Provider Business Mailing Address Fax Number:
562-453-3059

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
20620 LEAPWOOD AVE
Provider Second Line Business Practice Location Address:
SUITE H
Provider Business Practice Location Address City Name:
CARSON
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90746
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
310-294-9027
Provider Business Practice Location Address Fax Number:
562-453-3059
Provider Enumeration Date:
07/06/2018

Additional Information

Authorized Official

Authorized Official Last Name:
RUSSMAN
Authorized Official First Name:
F.
Authorized Official Middle Name:
MARINA
Authorized Official Title or Position:
MEDICAL DIRECTOR/OWNER
Authorized Official Telephone Number:
310-294-9027

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 171100000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208VP0000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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