Provider Demographics
NPI:1700849247
Name:PAIN MANAGEMENT INTERVENTIONS, LLC
Entity Type:Organization
Organization Name:PAIN MANAGEMENT INTERVENTIONS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BENJAMIN
Authorized Official - Middle Name:
Authorized Official - Last Name:SOETER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:219-983-8300
Mailing Address - Street 1:PO BOX 393
Mailing Address - Street 2:
Mailing Address - City:POPLAR BLUFF
Mailing Address - State:MO
Mailing Address - Zip Code:63902-0393
Mailing Address - Country:US
Mailing Address - Phone:573-785-4601
Mailing Address - Fax:573-776-6127
Practice Address - Street 1:2000 ROOSEVELT RD
Practice Address - Street 2:
Practice Address - City:VALPARAISO
Practice Address - State:IN
Practice Address - Zip Code:46383-2800
Practice Address - Country:US
Practice Address - Phone:219-983-8300
Practice Address - Fax:573-776-6127
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-07
Last Update Date:2018-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO208VP0014X
IN208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO505222703Medicaid
MO505222703Medicaid