Provider Demographics
NPI:1629229869
Name:INTERVENTIONAL PAIN CONSULTANTS PA
Entity Type:Organization
Organization Name:INTERVENTIONAL PAIN CONSULTANTS PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:TERI
Authorized Official - Middle Name:
Authorized Official - Last Name:PALUSO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-748-4315
Mailing Address - Street 1:2841 JUNIPER DR
Mailing Address - Street 2:
Mailing Address - City:LEWISTON
Mailing Address - State:ID
Mailing Address - Zip Code:83501-4719
Mailing Address - Country:US
Mailing Address - Phone:208-743-9712
Mailing Address - Fax:208-298-0212
Practice Address - Street 1:2841 JUNIPER DR
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:ID
Practice Address - Zip Code:83501-4719
Practice Address - Country:US
Practice Address - Phone:208-743-9712
Practice Address - Fax:208-298-0212
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-07
Last Update Date:2008-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1375523Medicare PIN