Provider Demographics
NPI:1477574408
Name:PHYSICIANS PAIN MANAGEMENT CENTER, INC.
Entity Type:Organization
Organization Name:PHYSICIANS PAIN MANAGEMENT CENTER, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CAMERON
Authorized Official - Middle Name:
Authorized Official - Last Name:GOVONLU
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:508-824-0035
Mailing Address - Street 1:1244 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:RAYNHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02767-1973
Mailing Address - Country:US
Mailing Address - Phone:508-824-0035
Mailing Address - Fax:508-823-6127
Practice Address - Street 1:1244 BROADWAY
Practice Address - Street 2:
Practice Address - City:RAYNHAM
Practice Address - State:MA
Practice Address - Zip Code:02767-1973
Practice Address - Country:US
Practice Address - Phone:508-824-0035
Practice Address - Fax:508-823-6127
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-23
Last Update Date:2009-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAM21102Medicare ID - Type Unspecified