1780745596 NPI number — PAIN MANAGEMENT CONSULTANTS, LLC

Table of content: (NPI 1780745596)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1780745596 NPI number — PAIN MANAGEMENT CONSULTANTS, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PAIN MANAGEMENT CONSULTANTS, 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:
1780745596
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/27/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1169 EASTERN PKWY
Provider Second Line Business Mailing Address:
SUITE 2211
Provider Business Mailing Address City Name:
LOUISVILLE
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
40217-1417
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
502-635-2775
Provider Business Mailing Address Fax Number:
502-371-0475

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1169 EASTERN PKWY
Provider Second Line Business Practice Location Address:
SUITE 2211
Provider Business Practice Location Address City Name:
LOUISVILLE
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40217-1417
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-635-2775
Provider Business Practice Location Address Fax Number:
502-371-0475
Provider Enumeration Date:
12/13/2006

Additional Information

Authorized Official

Authorized Official Last Name:
WOLFSON
Authorized Official First Name:
KATHY
Authorized Official Middle Name:
Authorized Official Title or Position:
OFFICE MANAGER
Authorized Official Telephone Number:
502-635-2775

Provider Taxonomy Codes

  • Taxonomy code: 208VP0014X , with the licence number:  22581 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 261QP3300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 65903056 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 64225816 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 78903192 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 7100130090 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
  • Identifier: DA3323 . This is a "MEDICARE RR" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".




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