Provider Demographics
NPI:1942680194
Name:INTERVENTIONAL PAIN INSTITUTE
Entity Type:Organization
Organization Name:INTERVENTIONAL PAIN INSTITUTE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER AND PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIE
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:FUSSELL
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:304-241-5160
Mailing Address - Street 1:1288 SUNCREST TOWN CENTRE DR
Mailing Address - Street 2:
Mailing Address - City:MORGANTOWN
Mailing Address - State:WV
Mailing Address - Zip Code:26505-1828
Mailing Address - Country:US
Mailing Address - Phone:304-241-5160
Mailing Address - Fax:304-241-5167
Practice Address - Street 1:1288 SUNCREST TOWN CENTRE DR
Practice Address - Street 2:
Practice Address - City:MORGANTOWN
Practice Address - State:WV
Practice Address - Zip Code:26505-1828
Practice Address - Country:US
Practice Address - Phone:304-241-5160
Practice Address - Fax:304-241-5167
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-03
Last Update Date:2015-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV2511208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WVA51Medicare PIN