Provider Demographics
NPI:1881936029
Name:PAIN MANAGEMENT ASSOCIATES OF GLASTONBURY LLC
Entity type:Organization
Organization Name:PAIN MANAGEMENT ASSOCIATES OF GLASTONBURY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING SUPERVISOR
Authorized Official - Prefix:
Authorized Official - First Name:EWA
Authorized Official - Middle Name:
Authorized Official - Last Name:GASZEK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:860-282-4137
Mailing Address - Street 1:318 FELDSPAR RDG
Mailing Address - Street 2:
Mailing Address - City:GLASTONBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06033-3391
Mailing Address - Country:US
Mailing Address - Phone:860-759-0060
Mailing Address - Fax:860-633-6041
Practice Address - Street 1:394 W CENTER ST
Practice Address - Street 2:
Practice Address - City:MANCHESTER
Practice Address - State:CT
Practice Address - Zip Code:06040-4735
Practice Address - Country:US
Practice Address - Phone:860-759-0060
Practice Address - Fax:860-633-6041
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-03-26
Last Update Date:2013-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT207L00000X, 207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain MedicineGroup - Multi-Specialty
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Multi-Specialty