1003026253 NPI number — PAIN MANAGEMENT PC

Table of content: (NPI 1003026253)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1003026253 NPI number — PAIN MANAGEMENT PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PAIN MANAGEMENT PC
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:
1003026253
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/19/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
13811 CHARLES ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OMAHA
Provider Business Mailing Address State Name:
NE
Provider Business Mailing Address Postal Code:
68154-3883
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
402-492-8544
Provider Business Mailing Address Fax Number:
402-391-8979

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8031 W CENTER RD
Provider Second Line Business Practice Location Address:
SUITE 226
Provider Business Practice Location Address City Name:
OMAHA
Provider Business Practice Location Address State Name:
NE
Provider Business Practice Location Address Postal Code:
68124-3134
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
402-391-8978
Provider Business Practice Location Address Fax Number:
402-391-8979
Provider Enumeration Date:
05/23/2007

Additional Information

Authorized Official

Authorized Official Last Name:
PERRY
Authorized Official First Name:
MICHAEL
Authorized Official Middle Name:
KENT
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
402-492-8544

Provider Taxonomy Codes

  • Taxonomy code: 367500000X , with the licence number:  100507 , registered in the state of NE ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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