Provider Demographics
NPI:1568645869
Name:THE PAIN MANAGEMENT CENTER OF MIDCOAST MAINE
Entity Type:Organization
Organization Name:THE PAIN MANAGEMENT CENTER OF MIDCOAST MAINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DO OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:J
Authorized Official - Last Name:KAZALSKI
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:207-882-1113
Mailing Address - Street 1:PO BOX 810
Mailing Address - Street 2:
Mailing Address - City:WESTBROOK
Mailing Address - State:ME
Mailing Address - Zip Code:04098-0810
Mailing Address - Country:US
Mailing Address - Phone:207-854-1544
Mailing Address - Fax:207-854-1516
Practice Address - Street 1:721 BATH RD
Practice Address - Street 2:
Practice Address - City:WISCASSET
Practice Address - State:ME
Practice Address - Zip Code:04578
Practice Address - Country:US
Practice Address - Phone:207-882-1113
Practice Address - Fax:207-882-1114
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-10
Last Update Date:2008-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME1767208VP0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME262680000Medicaid
ME1912059353OtherINDIVIDUAL NPI #
ME0004966Medicare PIN
MEH02586Medicare UPIN