Provider Demographics
NPI:1619968120
Name:CENTER FOR PAIN MANAGEMENT, SC
Entity Type:Organization
Organization Name:CENTER FOR PAIN MANAGEMENT, SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:NOSHEEN
Authorized Official - Middle Name:
Authorized Official - Last Name:HASAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:414-444-8670
Mailing Address - Street 1:PO BOX 13857
Mailing Address - Street 2:
Mailing Address - City:WAUWATOSA
Mailing Address - State:WI
Mailing Address - Zip Code:53213-0857
Mailing Address - Country:US
Mailing Address - Phone:414-444-8670
Mailing Address - Fax:414-444-8678
Practice Address - Street 1:6200 W CENTER ST
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53210-2159
Practice Address - Country:US
Practice Address - Phone:414-444-8670
Practice Address - Fax:414-444-8678
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-03
Last Update Date:2017-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI207L00000X
208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain MedicineGroup - Single Specialty
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI21273400Medicaid
WI21273400Medicaid
WI000001182Medicare PIN