Provider Demographics
NPI:1477024743
Name:IC PAIN, LLC
Entity Type:Organization
Organization Name:IC PAIN, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DO
Authorized Official - Prefix:
Authorized Official - First Name:KIP
Authorized Official - Middle Name:CARDELL
Authorized Official - Last Name:NEWELL
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:402-547-9405
Mailing Address - Street 1:NORTHWEST MEDICAL CENTER
Mailing Address - Street 2:2210 BARRON RD, SUITE 203
Mailing Address - City:POPLAR BLUFF
Mailing Address - State:MD
Mailing Address - Zip Code:63901
Mailing Address - Country:US
Mailing Address - Phone:573-776-0157
Mailing Address - Fax:573-776-6504
Practice Address - Street 1:NORTHWEST MEDICAL CENTER
Practice Address - Street 2:2210 BARRON RD, SUITE 203
Practice Address - City:POPLAR BLUFF
Practice Address - State:MD
Practice Address - Zip Code:63901
Practice Address - Country:US
Practice Address - Phone:573-776-0157
Practice Address - Fax:573-776-6504
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-12-16
Last Update Date:2018-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty