MEDICARE: INTERVENTIONS IN PAIN MANAGEMENT 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	:	1891247904
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	INTERVENTIONS IN PAIN MANAGEMENT LLC

Provider Business Mailing Address
First Line	:	4110 BLACKHAWK RD STE 2
Second Line	:
City	:	ROCK ISLAND
State	:	IL
Zip	:	61201-7039
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3509 SPRING ST STE 3
Second Line	:
City	:	DAVENPORT
State	:	IA
Zip	:	52807-2124
Country	:	US
Telephone Number	:	309-428-7055
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	KERRY PANOZZO
Credential	:	M.D.
Telephone Number	:	309-721-3288

Provider Enumeration Date	:	10/25/2016
Last Update Date	:	04/03/2017

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