Provider Demographics
NPI:1457533937
Name:INTERVENTIONAL PAIN CONSULTANTS PA
Entity Type:Organization
Organization Name:INTERVENTIONAL PAIN CONSULTANTS PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:THOMAS
Authorized Official - Last Name:GRISSOM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:208-743-9712
Mailing Address - Street 1:2841 JUNIPER DR
Mailing Address - Street 2:
Mailing Address - City:LEWISTON
Mailing Address - State:ID
Mailing Address - Zip Code:83501-4719
Mailing Address - Country:US
Mailing Address - Phone:208-743-9712
Mailing Address - Fax:208-748-4312
Practice Address - Street 1:2841 JUNIPER DR
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:ID
Practice Address - Zip Code:83501-4719
Practice Address - Country:US
Practice Address - Phone:208-743-9712
Practice Address - Fax:208-748-4312
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-27
Last Update Date:2007-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty