Provider Demographics
NPI:1679514087
Name:PAIN MANAGEMENT PHYSICIANS, LLC
Entity Type:Organization
Organization Name:PAIN MANAGEMENT PHYSICIANS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:
Authorized Official - Last Name:STREET
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:573-815-2700
Mailing Address - Street 1:PO BOX 7096
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95267
Mailing Address - Country:US
Mailing Address - Phone:209-956-7725
Mailing Address - Fax:209-956-7733
Practice Address - Street 1:1601 E BROADWAY
Practice Address - Street 2:LOWER LEVEL
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65201
Practice Address - Country:US
Practice Address - Phone:573-815-2700
Practice Address - Fax:573-815-3693
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-09
Last Update Date:2012-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO501869903Medicaid
MODE8732Medicare PIN
MO000014891Medicare PIN