Provider Demographics
NPI:1710018247
Name:INTERVENTIONAL PAIN MANAGEMENT
Entity Type:Organization
Organization Name:INTERVENTIONAL PAIN MANAGEMENT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MAHENDRA
Authorized Official - Middle Name:
Authorized Official - Last Name:GUNAPOOTI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:314-830-2600
Mailing Address - Street 1:PO BOX 650
Mailing Address - Street 2:
Mailing Address - City:EDWARDSVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62025-0650
Mailing Address - Country:US
Mailing Address - Phone:314-450-8810
Mailing Address - Fax:314-678-0583
Practice Address - Street 1:261 DUNN RD
Practice Address - Street 2:
Practice Address - City:FLORISSANT
Practice Address - State:MO
Practice Address - Zip Code:63031-7928
Practice Address - Country:US
Practice Address - Phone:314-450-8810
Practice Address - Fax:314-678-0583
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-08
Last Update Date:2017-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036112334208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL6032125OtherBLUE CROSS BLUE SHIELD
IL6032125OtherBLUE CROSS BLUE SHIELD
MO000014465Medicare ID - Type Unspecified