MEDICARE: DOWNTOWN PAIN MANAGEMENT CLINIC, 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	207R00000X	Internal Medicine Physician	4301089175	MO
2	208100000X	Physical Medicine & Rehabilitation Physician	4301089175	MO

General Provider Information

NPI Number	:	1598903585
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DOWNTOWN PAIN MANAGEMENT CLINIC, LLC

Provider Business Mailing Address
First Line	:	703 OLIVE ST
Second Line	:	SUITE 211
City	:	SAINT LOUIS
State	:	MO
Zip	:	63101-2202
Country	:	US
Telephone Number	:	314-588-8511
Fax Number	:

Provider Business Practice Location Address
First Line	:	703 OLIVE ST
Second Line	:	SUITE 211
City	:	SAINT LOUIS
State	:	MO
Zip	:	63101-2202
Country	:	US
Telephone Number	:	314-588-8511
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	MITCHELL LIBERMAN
Credential	:
Telephone Number	:	314-588-8511

Provider Enumeration Date	:	01/28/2009
Last Update Date	:	02/02/2009

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