Provider Demographics
NPI:1881866754
Name:PROGRESSIVE PAIN MANAGEMENT INC
Entity Type:Organization
Organization Name:PROGRESSIVE PAIN MANAGEMENT INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD
Authorized Official - Prefix:
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:ROGER
Authorized Official - Last Name:EDELEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:520-233-6502
Mailing Address - Street 1:PO BOX 21915
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85277-1915
Mailing Address - Country:US
Mailing Address - Phone:520-836-8644
Mailing Address - Fax:520-836-2499
Practice Address - Street 1:1653 E MCMURRAY BLVD STE 144
Practice Address - Street 2:
Practice Address - City:CASA GRANDE
Practice Address - State:AZ
Practice Address - Zip Code:85122-5934
Practice Address - Country:US
Practice Address - Phone:520-836-8644
Practice Address - Fax:520-836-2499
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-31
Last Update Date:2018-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ30267207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ368269Medicaid
AZZ121830Medicare PIN