Provider Demographics
NPI:1891137220
Name:INTERVENTIONAL PAIN CENTER, PLLC.
Entity Type:Organization
Organization Name:INTERVENTIONAL PAIN CENTER, PLLC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:K
Authorized Official - Last Name:KETROSER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:952-236-7610
Mailing Address - Street 1:10653 WAYZATA BLVD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:MINNETONKA
Mailing Address - State:MN
Mailing Address - Zip Code:55305-1528
Mailing Address - Country:US
Mailing Address - Phone:952-236-7610
Mailing Address - Fax:952-426-0674
Practice Address - Street 1:10653 WAYZATA BLVD
Practice Address - Street 2:SUITE 200
Practice Address - City:MINNETONKA
Practice Address - State:MN
Practice Address - Zip Code:55305-1528
Practice Address - Country:US
Practice Address - Phone:952-236-7610
Practice Address - Fax:952-426-0674
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-07-26
Last Update Date:2014-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3852111N00000X
MN34220207X00000X
MN447602081P2900X
MN243162084N0400X
MN42871208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain MedicineGroup - Multi-Specialty
No111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty
No2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Multi-Specialty
No208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain MedicineGroup - Multi-Specialty