1255571410 NPI number — PAIN MANAGEMENT PSYCHOLOGY SERVICES, PA

Table of content: (NPI 1255571410)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1255571410 NPI number — PAIN MANAGEMENT PSYCHOLOGY SERVICES, PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PAIN MANAGEMENT PSYCHOLOGY SERVICES, PA
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:
1255571410
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/18/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
160 KIMEL FOREST DR.
Provider Second Line Business Mailing Address:
STE. 100
Provider Business Mailing Address City Name:
WINSTON-SALEM
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
27103-6084
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
336-770-6451
Provider Business Mailing Address Fax Number:
336-714-6475

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
160 KIMEL FOREST DR.
Provider Second Line Business Practice Location Address:
STE. 100
Provider Business Practice Location Address City Name:
WINSTON-SALEM
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27103-6084
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
336-770-6451
Provider Business Practice Location Address Fax Number:
336-714-6475
Provider Enumeration Date:
03/02/2009

Additional Information

Authorized Official

Authorized Official Last Name:
WEBSTER
Authorized Official First Name:
TIMOTHY
Authorized Official Middle Name:
NORRIS
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
336-770-6451

Provider Taxonomy Codes

  • Taxonomy code: 103T00000X , with the licence number:  0388 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 6006753 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 616591400 . This is a "DOL/OWCP (DEPARTMENT OF LABOR OFFICE OF WORKERS COMPENSATION PROGRAMS)" identifier . This identifiers is of the category "OTHER".




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