Provider Demographics
NPI:1295827665
Name:PAIN TREATMENT CENTER INC
Entity Type:Organization
Organization Name:PAIN TREATMENT CENTER INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:GRAHAM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:314-872-5601
Mailing Address - Street 1:PO BOX 953010
Mailing Address - Street 2:
Mailing Address - City:ST LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63195-3010
Mailing Address - Country:US
Mailing Address - Phone:314-872-5601
Mailing Address - Fax:314-872-5628
Practice Address - Street 1:2821 N BALLAS RD
Practice Address - Street 2:SUITE C-11
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63131-2321
Practice Address - Country:US
Practice Address - Phone:314-872-5601
Practice Address - Fax:314-872-5628
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-29
Last Update Date:2010-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO109904207LP2900X
IL036092540207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
115491OtherMERCY
050065227OtherRR MEDICARE
2000288OtherUNITED HEATHCARE
MO28931OtherCMR
0004669135OtherAETNA
MO114762OtherBCBS
28931OtherGHP ASO LHI
30087OtherGHP
322628OtherHEALTHLINK
514766005OtherTRICARE NORTH WEST
2000288OtherUNITED HEATHCARE
322628OtherHEALTHLINK
F36415Medicare UPIN