Provider Demographics
NPI:1669789889
Name:PAIN MANAGEMENT SOLUTION LLC
Entity type:Organization
Organization Name:PAIN MANAGEMENT SOLUTION LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:S
Authorized Official - Last Name:MASIMORE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:317-346-7246
Mailing Address - Street 1:730 EXECUTIVE PARK DR STE A
Mailing Address - Street 2:
Mailing Address - City:GREENWOOD
Mailing Address - State:IN
Mailing Address - Zip Code:46143-3213
Mailing Address - Country:US
Mailing Address - Phone:317-346-7246
Mailing Address - Fax:317-543-3763
Practice Address - Street 1:730 EXECUTIVE PARK DR STE A
Practice Address - Street 2:
Practice Address - City:GREENWOOD
Practice Address - State:IN
Practice Address - Zip Code:46143-3213
Practice Address - Country:US
Practice Address - Phone:317-346-7246
Practice Address - Fax:317-543-3763
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-09
Last Update Date:2019-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain MedicineGroup - Multi-Specialty
No208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200997010CMedicaid
IN200997010AMedicaid
6466550001Medicare PIN
IN200997010AMedicaid