Provider Demographics
NPI:1821717711
Name:PAIN MANAGEMENT 360 LLC
Entity Type:Organization
Organization Name:PAIN MANAGEMENT 360 LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RUDY
Authorized Official - Middle Name:
Authorized Official - Last Name:MALAYIL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:917-645-2591
Mailing Address - Street 1:PO BOX 33821
Mailing Address - Street 2:
Mailing Address - City:BELFAST
Mailing Address - State:ME
Mailing Address - Zip Code:04915-0616
Mailing Address - Country:US
Mailing Address - Phone:888-488-8289
Mailing Address - Fax:304-577-8615
Practice Address - Street 1:551 21ST ST
Practice Address - Street 2:
Practice Address - City:HUNTINGTON
Practice Address - State:WV
Practice Address - Zip Code:25703-1540
Practice Address - Country:US
Practice Address - Phone:917-935-7788
Practice Address - Fax:304-577-8615
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-08-24
Last Update Date:2024-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain MedicineGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0000210Medicaid
KY7100858920Medicaid
KY7100858910Medicaid
WV1821717711Medicaid