Provider Demographics
NPI:1801831631
Name:INTERVENTIONAL PAIN SPECIALISTS OF SO CA
Entity Type:Organization
Organization Name:INTERVENTIONAL PAIN SPECIALISTS OF SO CA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:619-299-1767
Mailing Address - Street 1:PO BOX 969096
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92196-9096
Mailing Address - Country:US
Mailing Address - Phone:858-495-0971
Mailing Address - Fax:858-495-0991
Practice Address - Street 1:7485 MISSION VALLEY RD
Practice Address - Street 2:STE 104B
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92108-4422
Practice Address - Country:US
Practice Address - Phone:619-299-1767
Practice Address - Fax:619-299-0925
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-17
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW15776Medicare ID - Type Unspecified