Provider Demographics
NPI:1013280973
Name:PAIN MANAGEMENT CENTERS OF ST. LOUIS, INC.
Entity Type:Organization
Organization Name:PAIN MANAGEMENT CENTERS OF ST. LOUIS, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:MITCHELL
Authorized Official - Middle Name:
Authorized Official - Last Name:LIBERMAN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:314-374-3408
Mailing Address - Street 1:8045 BIG BEND BLVD
Mailing Address - Street 2:SUITE 201
Mailing Address - City:WEBSTER GROVES
Mailing Address - State:MO
Mailing Address - Zip Code:63119-2714
Mailing Address - Country:US
Mailing Address - Phone:314-374-3408
Mailing Address - Fax:
Practice Address - Street 1:8045 BIG BEND BLVD
Practice Address - Street 2:SUITE 201
Practice Address - City:WEBSTER GROVES
Practice Address - State:MO
Practice Address - Zip Code:63119-2714
Practice Address - Country:US
Practice Address - Phone:314-374-3408
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-22
Last Update Date:2012-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20070015402081P2900X
MO112767208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain MedicineGroup - Multi-Specialty
No208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty