Provider Demographics
NPI:1114171519
Name:ADVANCED PAIN MANAGEMENT PLLC
Entity Type:Organization
Organization Name:ADVANCED PAIN MANAGEMENT PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:DALE
Authorized Official - Last Name:SEVERSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:208-880-9464
Mailing Address - Street 1:6140 CURTISIAN AVE
Mailing Address - Street 2:SUITE 400
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83704-8880
Mailing Address - Country:US
Mailing Address - Phone:208-327-5600
Mailing Address - Fax:208-367-2968
Practice Address - Street 1:2275 SO EAGLE RD
Practice Address - Street 2:SUTE 160
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642
Practice Address - Country:US
Practice Address - Phone:208-947-2266
Practice Address - Fax:208-947-2267
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-11
Last Update Date:2011-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID808339800Medicaid
ID808339800Medicaid
DO8773Medicare PIN