Provider Demographics
NPI:1497288971
Name:INTERVENTIONAL CENTER FOR PAIN
Entity Type:Organization
Organization Name:INTERVENTIONAL CENTER FOR PAIN
Other - Org Name:CENTER FOR INTERVENTIONAL PAIN MANAGEMENT
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:GURPREET
Authorized Official - Middle Name:S
Authorized Official - Last Name:PADDA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:314-481-5000
Mailing Address - Street 1:5203 CHIPPEWA ST
Mailing Address - Street 2:SUITE 301
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63109-2356
Mailing Address - Country:US
Mailing Address - Phone:314-481-5000
Mailing Address - Fax:314-481-3037
Practice Address - Street 1:5203 CHIPPEWA ST
Practice Address - Street 2:SUITE 301
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63109-2356
Practice Address - Country:US
Practice Address - Phone:314-481-5000
Practice Address - Fax:314-481-3037
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-04-11
Last Update Date:2017-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2016043827364SA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes364SA2200XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistAdult HealthGroup - Multi-Specialty