Healthcare Provider Details

I. General information

NPI: 1073293544
Provider Name (Legal Business Name): PAIN EXPERTS OF ARIZONA PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/20/2023
Last Update Date: 07/20/2023
Certification Date: 07/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4566 E INVERNESS AVE STE 202
MESA AZ
85206-4634
US

IV. Provider business mailing address

PO BOX 29650
PHOENIX AZ
85038-9650
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 Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State
# 3
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