Provider Demographics
NPI:1912195330
Name:MIDCITIES PAIN CENTER, LLC
Entity Type:Organization
Organization Name:MIDCITIES PAIN CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:TED
Authorized Official - Middle Name:
Authorized Official - Last Name:GROESBECK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:469-682-6742
Mailing Address - Street 1:PO BOX 269083
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73126-9083
Mailing Address - Country:US
Mailing Address - Phone:972-479-1115
Mailing Address - Fax:972-346-8013
Practice Address - Street 1:1600 W NORTHWEST HWY
Practice Address - Street 2:STE. 1000
Practice Address - City:GRAPEVINE
Practice Address - State:TX
Practice Address - Zip Code:76051-8112
Practice Address - Country:US
Practice Address - Phone:817-488-9991
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-10
Last Update Date:2008-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
No261QP3300XAmbulatory Health Care FacilitiesClinic/CenterPain