MEDICARE: PENN INTERVENTIONAL PAIN CENTER, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QP3300X	Pain Clinic/Center

General Provider Information

NPI Number	:	1124310073
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PENN INTERVENTIONAL PAIN CENTER, LLC

Provider Business Mailing Address
First Line	:	PO BOX 268934
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73126-8934
Country	:	US
Telephone Number	:	972-234-4740
Fax Number	:	817-571-0897

Provider Business Practice Location Address
First Line	:	1201 SUMMIT AVE
Second Line	:	SUITE 400
City	:	FORT WORTH
State	:	TX
Zip	:	76102-4413
Country	:	US
Telephone Number	:	972-234-4740
Fax Number	:	817-571-0897

Authorized Official
Title or Position	:	MANAGER
Name	:	TED GROSBECK
Credential	:
Telephone Number	:	469-362-6909

Provider Enumeration Date	:	05/11/2011
Last Update Date	:	05/11/2011

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