Provider Demographics
NPI:1164690160
Name:PHOENIX PAIN TREATMENT CENTER
Entity Type:Organization
Organization Name:PHOENIX PAIN TREATMENT CENTER
Other - Org Name:INTEGRATED ADDICTION MEDICINE
Other - Org Type:Other Name
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:MURRAY
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:602-244-9200
Mailing Address - Street 1:3124 E ROOSEVELT ST # D-2
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85008-5088
Mailing Address - Country:US
Mailing Address - Phone:602-244-9200
Mailing Address - Fax:602-244-9222
Practice Address - Street 1:3124 E ROOSEVELT ST # D-2
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85008-5088
Practice Address - Country:US
Practice Address - Phone:602-244-9200
Practice Address - Fax:602-244-9222
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-13
Last Update Date:2008-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLISAC-10277101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ105694Medicare Oscar/Certification