Healthcare Provider Details

I. General information

NPI: 1619407533
Provider Name (Legal Business Name): PAIN INSTITUTE OF SOUTHERN ARIZONA PISA PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/13/2017
Last Update Date: 01/28/2021
Certification Date: 01/28/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4881 E GRANT RD STE 101
TUCSON AZ
85712-2704
US

IV. Provider business mailing address

4582 N 1ST AVE STE 170
TUCSON AZ
85718-8607
US

V. Phone/Fax

Practice location:
  • Phone: 520-336-5174
  • Fax: 520-795-9953
Mailing address:
  • Phone: 520-505-3766
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. KENNETH B GOSSLER
Title or Position: PHYSICIAN/OWNER
Credential: MD
Phone: 520-318-6035