1902240054 NPI number — PAIN MANAGEMENT CARE, P.C.

Table of content: (NPI 1902240054)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1902240054 NPI number — PAIN MANAGEMENT CARE, P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PAIN MANAGEMENT CARE, 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:
1902240054
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/14/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2106 IRONWOOD CIR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SOUTH BEND
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46635-1864
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
574-247-4682
Provider Business Mailing Address Fax Number:
574-247-4785

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
707 N RIVER DR
Provider Second Line Business Practice Location Address:
SUITE C
Provider Business Practice Location Address City Name:
MARION
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46952-2765
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
765-662-0155
Provider Business Practice Location Address Fax Number:
765-662-0166
Provider Enumeration Date:
04/19/2013

Additional Information

Authorized Official

Authorized Official Last Name:
GLAZIER
Authorized Official First Name:
JOSEPH
Authorized Official Middle Name:
G
Authorized Official Title or Position:
SOLE PROPRIETOR
Authorized Official Telephone Number:
574-247-4682

Provider Taxonomy Codes

  • Taxonomy code: 208VP0014X , with the licence number:  01024859A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 100343010A , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".




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