1588183008 NPI number — MMIDDLETOWN INTERVENTIONAL PAIN MANAGEMENT, P.C.

Table of content: (NPI 1588183008)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1588183008 NPI number — MMIDDLETOWN INTERVENTIONAL PAIN MANAGEMENT, P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MMIDDLETOWN INTERVENTIONAL PAIN MANAGEMENT, P.C.
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:
1588183008
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/24/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
14502 W MEEKER BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SUN CITY WEST
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85375-5282
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
623-524-8814
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
MIDDLETOWN INTERVENTIONAL PAIN MANAGEMENT, P.C.
Provider Second Line Business Practice Location Address:
400 ROUTE 211 EAST SUITE 12
Provider Business Practice Location Address City Name:
MIDDLETOWN
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
10940-2123
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
845-381-1164
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/15/2017

Additional Information

Authorized Official

Authorized Official Last Name:
IZEOGU
Authorized Official First Name:
CHINWEIKE
Authorized Official Middle Name:
Authorized Official Title or Position:
MEDICAL DOCTOR
Authorized Official Telephone Number:
845-381-1164

Provider Taxonomy Codes

  • Taxonomy code: 208VP0014X , with the licence number:  235169 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207LP2900X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 235169 . This is a "MEDICAL LICENSE NUMBER" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".




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