Provider Demographics
NPI:1568958171
Name:FMR INTERVENTIONAL QUALITY PAIN MANAGEMENT, A PROFESSIONAL CORP
Entity Type:Organization
Organization Name:FMR INTERVENTIONAL QUALITY PAIN MANAGEMENT, A PROFESSIONAL CORP
Other - Org Name:FMR INTERVENTIONAL QPM
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEDICAL DIRECTOR/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:F.
Authorized Official - Middle Name:MARINA
Authorized Official - Last Name:RUSSMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:310-294-9027
Mailing Address - Street 1:12415 NORWALK BLVD
Mailing Address - Street 2:UNIT 59600
Mailing Address - City:NORWALK
Mailing Address - State:CA
Mailing Address - Zip Code:90652
Mailing Address - Country:US
Mailing Address - Phone:310-294-9027
Mailing Address - Fax:562-453-3059
Practice Address - Street 1:20620 LEAPWOOD AVE
Practice Address - Street 2:SUITE H
Practice Address - City:CARSON
Practice Address - State:CA
Practice Address - Zip Code:90746
Practice Address - Country:US
Practice Address - Phone:310-294-9027
Practice Address - Fax:562-453-3059
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-07-06
Last Update Date:2023-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain MedicineGroup - Multi-Specialty
No111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
No171100000XOther Service ProvidersAcupuncturistGroup - Multi-Specialty