Provider Demographics
NPI:1972910990
Name:ANTHEM PAIN MANAGEMENT, LLC
Entity Type:Organization
Organization Name:ANTHEM PAIN MANAGEMENT, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FAMILY NURSE PRACTITIONER
Authorized Official - Prefix:
Authorized Official - First Name:KEITH
Authorized Official - Middle Name:R
Authorized Official - Last Name:SUTTON
Authorized Official - Suffix:
Authorized Official - Credentials:FNP
Authorized Official - Phone:623-341-8469
Mailing Address - Street 1:41818 N VENTURE DR STE 150
Mailing Address - Street 2:
Mailing Address - City:ANTHEM
Mailing Address - State:AZ
Mailing Address - Zip Code:85086-3190
Mailing Address - Country:US
Mailing Address - Phone:716-812-6664
Mailing Address - Fax:
Practice Address - Street 1:41818 N VENTURE DR STE 150
Practice Address - Street 2:
Practice Address - City:ANTHEM
Practice Address - State:AZ
Practice Address - Zip Code:85086-3190
Practice Address - Country:US
Practice Address - Phone:623-341-8469
Practice Address - Fax:623-551-6900
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-22
Last Update Date:2016-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAP3009302R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZAP3009OtherAZ NP LICENSE
AZ506568Medicaid
AZAP3009OtherAZ NP LICENSE