Provider Demographics
NPI:1396783338
Name:PAIN MANAGEMENT & REHAB CONSULT
Entity type:Organization
Organization Name:PAIN MANAGEMENT & REHAB CONSULT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER BILLING
Authorized Official - Prefix:MRS
Authorized Official - First Name:FELISHA
Authorized Official - Middle Name:F
Authorized Official - Last Name:HARP
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:479-587-1753
Mailing Address - Street 1:PO BOX 9928
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72701
Mailing Address - Country:US
Mailing Address - Phone:479-587-8753
Mailing Address - Fax:479-587-8754
Practice Address - Street 1:2531 TINAS CROSSING
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72703
Practice Address - Country:US
Practice Address - Phone:479-587-8753
Practice Address - Fax:479-587-8754
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-03
Last Update Date:2008-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE4333174400000X
ARMC2421208VP0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain MedicineGroup - Multi-Specialty
No174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR15611001Medicaid
AR5F234Medicare UPIN
AR15611001Medicaid