Provider Demographics
NPI:1619233079
Name:ADVANCED PAIN MEDICINE PC
Entity Type:Organization
Organization Name:ADVANCED PAIN MEDICINE PC
Other - Org Name:ADVANCED PAIN MEDICINE MOON
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:LODICO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:724-933-0300
Mailing Address - Street 1:7000 STONEWOOD DR
Mailing Address - Street 2:STE 151
Mailing Address - City:WEXFORD
Mailing Address - State:PA
Mailing Address - Zip Code:15090-7376
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1009 BEAVER GRADE RD
Practice Address - Street 2:STE 100
Practice Address - City:MOON TWP
Practice Address - State:PA
Practice Address - Zip Code:15108-2969
Practice Address - Country:US
Practice Address - Phone:724-933-0300
Practice Address - Fax:724-933-0456
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-10
Last Update Date:2022-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0077653000002Medicaid