1952655110 NPI number — PMC PAIN MANAGEMENT CENTER PLLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1952655110 NPI number — PMC PAIN MANAGEMENT CENTER PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PMC PAIN MANAGEMENT CENTER PLLC
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:
1952655110
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/02/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8914 N.91 AVE
Provider Second Line Business Mailing Address:
SUITE 100B
Provider Business Mailing Address City Name:
PEORIA
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85260
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
623-877-0100
Provider Business Mailing Address Fax Number:
623-328-7386

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8914 N.91 AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PEORIA
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85345
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
623-877-0100
Provider Business Practice Location Address Fax Number:
623-328-7386
Provider Enumeration Date:
11/08/2012

Additional Information

Authorized Official

Authorized Official Last Name:
GOLD
Authorized Official First Name:
GARY
Authorized Official Middle Name:
Authorized Official Title or Position:
PARTNER
Authorized Official Telephone Number:
602-703-7276

Provider Taxonomy Codes

  • Taxonomy code: 261QP3300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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