Provider Demographics
NPI:1437349578
Name:PAIN CONTROL ASSOCIATES OF SAN DIEGO, INC.
Entity Type:Organization
Organization Name:PAIN CONTROL ASSOCIATES OF SAN DIEGO, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:H
Authorized Official - Last Name:VERDOLIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:619-271-1683
Mailing Address - Street 1:2452 FENTON ST
Mailing Address - Street 2:SUITE 101
Mailing Address - City:CHULA VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:91914-3599
Mailing Address - Country:US
Mailing Address - Phone:619-271-1683
Mailing Address - Fax:619-651-7033
Practice Address - Street 1:2452 FENTON ST
Practice Address - Street 2:SUITE 101
Practice Address - City:CHULA VISTA
Practice Address - State:CA
Practice Address - Zip Code:91914-4551
Practice Address - Country:US
Practice Address - Phone:619-271-1683
Practice Address - Fax:619-651-7033
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-25
Last Update Date:2008-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA 92149208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW21019Medicare PIN