Provider Demographics
NPI:1255494985
Name:PAIN MANAGEMENT CONSULTANTS OF MILWAUKEE, S.C.
Entity Type:Organization
Organization Name:PAIN MANAGEMENT CONSULTANTS OF MILWAUKEE, S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MEHRAN
Authorized Official - Middle Name:
Authorized Official - Last Name:HEYDARPOUR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:262-780-0770
Mailing Address - Street 1:PO BOX 1413
Mailing Address - Street 2:
Mailing Address - City:BROOKFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53008-1413
Mailing Address - Country:US
Mailing Address - Phone:262-780-0770
Mailing Address - Fax:
Practice Address - Street 1:125 N EXECUTIVE DR
Practice Address - Street 2:SUITE 108
Practice Address - City:BROOKFIELD
Practice Address - State:WI
Practice Address - Zip Code:53005-6070
Practice Address - Country:US
Practice Address - Phone:262-780-0770
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-17
Last Update Date:2013-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
46189Medicare ID - Type Unspecified