Provider Demographics
NPI:1487022323
Name:PRIME MEDICAL PAIN MANAGEMENT CENTER
Entity Type:Organization
Organization Name:PRIME MEDICAL PAIN MANAGEMENT CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ROGER
Authorized Official - Middle Name:
Authorized Official - Last Name:BAKER
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:602-300-4754
Mailing Address - Street 1:4527 N 27TH AVE
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85017-3702
Mailing Address - Country:US
Mailing Address - Phone:602-300-4754
Mailing Address - Fax:602-249-1614
Practice Address - Street 1:4527 N 27TH AVE
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85017-3702
Practice Address - Country:US
Practice Address - Phone:602-300-4754
Practice Address - Fax:602-249-1614
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-09-09
Last Update Date:2015-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP3300XAmbulatory Health Care FacilitiesClinic/CenterPain