Provider Demographics
NPI:1225130131
Name:PROFESSIONAL PAIN MANAGMENT ASSOCIATES, PC
Entity Type:Organization
Organization Name:PROFESSIONAL PAIN MANAGMENT ASSOCIATES, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JASON
Authorized Official - Middle Name:C
Authorized Official - Last Name:CWIK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:215-829-3867
Mailing Address - Street 1:804 SCOTT NIXON MEMORIAL DR
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30907-2464
Mailing Address - Country:US
Mailing Address - Phone:800-394-4445
Mailing Address - Fax:706-650-1034
Practice Address - Street 1:1098 W BALTIMORE PIKE
Practice Address - Street 2:SUITE 3306
Practice Address - City:MEDIA
Practice Address - State:PA
Practice Address - Zip Code:19063-5139
Practice Address - Country:US
Practice Address - Phone:215-925-0986
Practice Address - Fax:215-829-0446
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-01
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA104787VUAMedicare PIN