Provider Demographics
NPI:1639248578
Name:TENDER PAIN CARE CLINIC, PSC
Entity Type:Organization
Organization Name:TENDER PAIN CARE CLINIC, PSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MAZEN
Authorized Official - Middle Name:
Authorized Official - Last Name:KHAYAT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:502-589-9310
Mailing Address - Street 1:801 BARRET AVE
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40204-1747
Mailing Address - Country:US
Mailing Address - Phone:502-228-8020
Mailing Address - Fax:
Practice Address - Street 1:801 BARRET AVE
Practice Address - Street 2:SUITE 104
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40204-1747
Practice Address - Country:US
Practice Address - Phone:502-589-9310
Practice Address - Fax:502-583-5560
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-07
Last Update Date:2007-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY32485207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY00168Medicare PIN
KY00168001Medicare PIN