Provider Demographics
NPI:1639413347
Name:ADVANCED PAIN MANAGEMENT PA
Entity Type:Organization
Organization Name:ADVANCED PAIN MANAGEMENT PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:SHIRLEY
Authorized Official - Middle Name:
Authorized Official - Last Name:DEHARDT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:913-302-2703
Mailing Address - Street 1:3604 SADDLE RIDGE
Mailing Address - Street 2:
Mailing Address - City:INDEPENDENCE
Mailing Address - State:MO
Mailing Address - Zip Code:64057-2332
Mailing Address - Country:US
Mailing Address - Phone:913-302-2703
Mailing Address - Fax:
Practice Address - Street 1:C/O CENTERPOINT MEDICAL CENTER
Practice Address - Street 2:19550 E 39TH ST, STE 110
Practice Address - City:INDEPENDENCE
Practice Address - State:MO
Practice Address - Zip Code:64057-2353
Practice Address - Country:US
Practice Address - Phone:816-698-8900
Practice Address - Fax:816-698-8905
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-11-19
Last Update Date:2021-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS=========OtherTID