Provider Demographics
NPI:1619407533
Name:PAIN INSTITUTE OF SOUTHERN ARIZONA PISA PC
Entity Type:Organization
Organization Name:PAIN INSTITUTE OF SOUTHERN ARIZONA PISA PC
Other - Org Name:PAIN INSTITUTE OF SOUTHERN ARIZONA PISA PC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHYSICIAN/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:B
Authorized Official - Last Name:GOSSLER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:520-318-6035
Mailing Address - Street 1:4582 N 1ST AVE STE 170
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85718-8607
Mailing Address - Country:US
Mailing Address - Phone:520-505-3766
Mailing Address - Fax:
Practice Address - Street 1:4881 E GRANT RD STE 101
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85712-2704
Practice Address - Country:US
Practice Address - Phone:520-336-5174
Practice Address - Fax:520-795-9953
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PAIN INSTITUTE OF SOUTHERN ARIZONA PISA PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-06-13
Last Update Date:2021-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ954926Medicaid