Provider Demographics
NPI:1467863472
Name:DUBUQUE PAIN CLINIC
Entity Type:Organization
Organization Name:DUBUQUE PAIN CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:IVAN
Authorized Official - Middle Name:
Authorized Official - Last Name:FOMITCHEV
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:563-564-1283
Mailing Address - Street 1:2260 SAMANTHA DR
Mailing Address - Street 2:
Mailing Address - City:DUBUQUE
Mailing Address - State:IA
Mailing Address - Zip Code:52002-0485
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:250 MERCY DR
Practice Address - Street 2:
Practice Address - City:DUBUQUE
Practice Address - State:IA
Practice Address - Zip Code:52001-7320
Practice Address - Country:US
Practice Address - Phone:563-589-8665
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-05-13
Last Update Date:2014-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA34875208VP0000X, 208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain MedicineGroup - Multi-Specialty
No208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain MedicineGroup - Multi-Specialty