Provider Demographics
NPI:1114963501
Name:NORTHSHORE INTERVENTIONAL PAIN MANAGEMENT, APMC
Entity Type:Organization
Organization Name:NORTHSHORE INTERVENTIONAL PAIN MANAGEMENT, APMC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:PAULETTE
Authorized Official - Middle Name:
Authorized Official - Last Name:WATTS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:985-809-1997
Mailing Address - Street 1:7015 HIGHWAY 190 EAST SERVICE RD
Mailing Address - Street 2:STE. 101
Mailing Address - City:COVINGTON
Mailing Address - State:LA
Mailing Address - Zip Code:70433-4960
Mailing Address - Country:US
Mailing Address - Phone:985-809-1997
Mailing Address - Fax:985-809-1664
Practice Address - Street 1:7015 HIGHWAY 190 EAST SERVICE RD
Practice Address - Street 2:STE. 101
Practice Address - City:COVINGTON
Practice Address - State:LA
Practice Address - Zip Code:70433-4960
Practice Address - Country:US
Practice Address - Phone:985-809-1997
Practice Address - Fax:985-809-1664
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-22
Last Update Date:2015-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LADA3921OtherRAILROAD MEDICARE
LA174463900OtherOFFICE OF WORKERS COMP
LA174463900OtherOFFICE OF WORKERS COMP
LA174463900OtherOFFICE OF WORKERS COMP