Provider Demographics
NPI:1942470687
Name:MILLENNIUM PAIN MANAGEMENT, LLC
Entity Type:Organization
Organization Name:MILLENNIUM PAIN MANAGEMENT, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:COLEMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:314-756-8035
Mailing Address - Street 1:13131 TESSON FERRY RD
Mailing Address - Street 2:SUITE #105
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63128-3887
Mailing Address - Country:US
Mailing Address - Phone:314-756-8035
Mailing Address - Fax:314-756-8050
Practice Address - Street 1:13131 TESSON FERRY RD
Practice Address - Street 2:SUITE #105
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63128-3887
Practice Address - Country:US
Practice Address - Phone:314-756-8035
Practice Address - Fax:314-756-8050
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-10
Last Update Date:2009-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOMA1106Medicare PIN