1225130131 NPI number — PROFESSIONAL PAIN MANAGMENT ASSOCIATES, PC

Table of content: (NPI 1225130131)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1225130131 NPI number — PROFESSIONAL PAIN MANAGMENT ASSOCIATES, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PROFESSIONAL PAIN MANAGMENT ASSOCIATES, 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:
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:
1225130131
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/21/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
804 SCOTT NIXON MEMORIAL DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
AUGUSTA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30907-2464
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
800-394-4445
Provider Business Mailing Address Fax Number:
706-650-1034

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1098 W BALTIMORE PIKE
Provider Second Line Business Practice Location Address:
SUITE 3306
Provider Business Practice Location Address City Name:
MEDIA
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19063-5139
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-925-0986
Provider Business Practice Location Address Fax Number:
215-829-0446
Provider Enumeration Date:
09/01/2006

Additional Information

Authorized Official

Authorized Official Last Name:
CWIK
Authorized Official First Name:
JASON
Authorized Official Middle Name:
C
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
215-829-3867

Provider Taxonomy Codes

  • Taxonomy code: 207LP2900X , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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