Provider Demographics
NPI:1649416926
Name:CLEVELAND PAIN MANAGEMENT, PC
Entity Type:Organization
Organization Name:CLEVELAND PAIN MANAGEMENT, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:
Authorized Official - Last Name:DEROOS
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:423-614-5654
Mailing Address - Street 1:340 SUNSET DR NW
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:TN
Mailing Address - Zip Code:37312-5349
Mailing Address - Country:US
Mailing Address - Phone:423-614-5654
Mailing Address - Fax:423-614-5645
Practice Address - Street 1:340 SUNSET DR NW
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:TN
Practice Address - Zip Code:37312-5349
Practice Address - Country:US
Practice Address - Phone:423-614-5654
Practice Address - Fax:423-614-5645
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-17
Last Update Date:2010-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN1294111N00000X
TN9519208D00000X
TN1753363A00000X
TN1830363A00000X
TN15022363L00000X
TN13925363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
No111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
No363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute CareGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN4026063OtherBCBSTN
TN1513537Medicaid
TN3730366OtherMEDICARE
TN6231010001Medicare NSC
TN3730366OtherMEDICARE