Provider Demographics
NPI:1568682318
Name:INNOVATIVE PAIN CARE LLC
Entity Type:Organization
Organization Name:INNOVATIVE PAIN CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GORDON
Authorized Official - Middle Name:L
Authorized Official - Last Name:MORTENSEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:414-325-4370
Mailing Address - Street 1:3111 W RAWSON AVE
Mailing Address - Street 2:SUITE 210
Mailing Address - City:FRANKLIN
Mailing Address - State:WI
Mailing Address - Zip Code:53132-9417
Mailing Address - Country:US
Mailing Address - Phone:414-325-4370
Mailing Address - Fax:414-761-0713
Practice Address - Street 1:3111 W RAWSON AVE
Practice Address - Street 2:SUITE 210
Practice Address - City:FRANKLIN
Practice Address - State:WI
Practice Address - Zip Code:53132-9417
Practice Address - Country:US
Practice Address - Phone:414-325-4370
Practice Address - Fax:414-761-0713
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-26
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain MedicineGroup - Multi-Specialty