Provider Demographics
NPI:1588615777
Name:ADVANCED PAIN MANAGEMENT CENTER, PSC
Entity Type:Organization
Organization Name:ADVANCED PAIN MANAGEMENT CENTER, PSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JAIME
Authorized Official - Middle Name:
Authorized Official - Last Name:GUERRERO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:502-589-0900
Mailing Address - Street 1:1170 E. BROADWAY
Mailing Address - Street 2:SUITE 300
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40204-1761
Mailing Address - Country:US
Mailing Address - Phone:502-589-0900
Mailing Address - Fax:502-589-9075
Practice Address - Street 1:1170 E. BROADWAY
Practice Address - Street 2:SUITE 300
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40204-1761
Practice Address - Country:US
Practice Address - Phone:502-589-0900
Practice Address - Fax:502-589-9075
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-13
Last Update Date:2014-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY37035207L00000X, 208VP0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Multi-Specialty
No208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100039170Medicaid
IN200886370AMedicaid
KY7100039170Medicaid
KY00032Medicare PIN
KY=========OtherTRICARE GROUP NUMBER