1639336969 NPI number — NORTHEAST OHIO CENTER FOR PAIN MANAGEMENT, INC.

Table of content: (NPI 1639336969)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639336969 NPI number — NORTHEAST OHIO CENTER FOR PAIN MANAGEMENT, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NORTHEAST OHIO CENTER FOR PAIN MANAGEMENT, INC.
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:
6
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:
1639336969
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/22/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
60 S PLEASANT ST
Provider Second Line Business Mailing Address:
SUITE B
Provider Business Mailing Address City Name:
OBERLIN
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
44074-1633
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
440-774-7246
Provider Business Mailing Address Fax Number:
440-776-0129

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
60 S PLEASANT ST
Provider Second Line Business Practice Location Address:
SUITE B
Provider Business Practice Location Address City Name:
OBERLIN
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
44074-1633
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
440-774-7246
Provider Business Practice Location Address Fax Number:
440-776-0129
Provider Enumeration Date:
05/22/2008

Additional Information

Authorized Official

Authorized Official Last Name:
RAY
Authorized Official First Name:
RICHARD
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
440-774-7246

Provider Taxonomy Codes

  • Taxonomy code: 261QP3300X , with the licence number:  35-066948 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 000000215005 . This is a "ANTHEM BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".




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