Provider Demographics
NPI:1740584176
Name:CAPITAL CITY PAIN CARE LLC
Entity Type:Organization
Organization Name:CAPITAL CITY PAIN CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SARAH
Authorized Official - Middle Name:E
Authorized Official - Last Name:BLAKE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:614-442-0700
Mailing Address - Street 1:3600 OLENTANGY RIVER ROAD
Mailing Address - Street 2:BUILDING 480
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43214
Mailing Address - Country:US
Mailing Address - Phone:614-442-0700
Mailing Address - Fax:614-442-0701
Practice Address - Street 1:3600 OLENTANGY RIVER ROAD
Practice Address - Street 2:BUILDING 480
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43214
Practice Address - Country:US
Practice Address - Phone:614-442-0700
Practice Address - Fax:614-442-0701
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-28
Last Update Date:2015-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH3582586208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2476217Medicaid
OH2476217Medicaid