Healthcare Provider Details

I. General information

NPI: 1659931152
Provider Name (Legal Business Name): PAIN EXPERTS OF ARIZONA PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/17/2019
Last Update Date: 02/12/2020
Certification Date: 02/12/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3370 S MERCY RD STE 321
GILBERT AZ
85297-0414
US

IV. Provider business mailing address

3370 S MERCY RD STE 321
GILBERT AZ
85297-0414
US

V. Phone/Fax

Practice location:
  • Phone: 480-550-9393
  • Fax:
Mailing address:
  • Phone: 480-550-9393
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: AHDEV KUPPUSAMY
Title or Position: OWNER
Credential:
Phone: 480-550-9393