Provider Demographics
NPI:1487835500
Name:MOUNT AIRY PAIN MANAGEMENT CENTER INC.
Entity Type:Organization
Organization Name:MOUNT AIRY PAIN MANAGEMENT CENTER INC.
Other - Org Name:MOUNT AIRY PAIN PRACTICE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PAIN SPECIALIST, ANESTHESIOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:OBIOMA
Authorized Official - Middle Name:C
Authorized Official - Last Name:IRO-NWOKEUKWU
Authorized Official - Suffix:III
Authorized Official - Credentials:MD063864L
Authorized Official - Phone:215-848-1166
Mailing Address - Street 1:6613 CHEW AVE
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19119-2002
Mailing Address - Country:US
Mailing Address - Phone:215-848-1166
Mailing Address - Fax:215-842-0224
Practice Address - Street 1:6613 CHEW AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19119-2002
Practice Address - Country:US
Practice Address - Phone:215-848-1166
Practice Address - Fax:215-842-0224
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-16
Last Update Date:2016-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD063864L261QP3300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP3300XAmbulatory Health Care FacilitiesClinic/CenterPain
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0017587000011Medicaid
PA0227452Medicare PIN