1871729723 NPI number — PROFESSIONAL PHYSICIAN PAIN SERVICES, LLC

Table of content: (NPI 1871729723)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1871729723 NPI number — PROFESSIONAL PHYSICIAN PAIN SERVICES, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PROFESSIONAL PHYSICIAN PAIN SERVICES, 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:
1871729723
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/30/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4400 WILL ROGERS PKWY
Provider Second Line Business Mailing Address:
SUITE 105
Provider Business Mailing Address City Name:
OKLAHOMA CITY
Provider Business Mailing Address State Name:
OK
Provider Business Mailing Address Postal Code:
73108-1837
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
405-947-5557
Provider Business Mailing Address Fax Number:
405-948-6507

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
114 PIPER HILL DR
Provider Second Line Business Practice Location Address:
SUITE 103
Provider Business Practice Location Address City Name:
SAINT PETERS
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
63376-1661
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
636-442-5035
Provider Business Practice Location Address Fax Number:
636-442-5036
Provider Enumeration Date:
06/05/2009

Additional Information

Authorized Official

Authorized Official Last Name:
NEAL
Authorized Official First Name:
DEBORAH
Authorized Official Middle Name:
Authorized Official Title or Position:
COORDINATOR
Authorized Official Telephone Number:
405-947-5557

Provider Taxonomy Codes

  • Taxonomy code: 207LP2900X , with the licence number:  2004009978 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207LP2900X , with the licence number: 2006018031 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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





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