Healthcare Provider Details

I. General information

NPI: 1154630044
Provider Name (Legal Business Name): ACADIA PAIN MANAGEMENT GROUP, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/27/2010
Last Update Date: 11/04/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4704 HOEN AVE
SANTA ROSA CA
95405-7824
US

IV. Provider business mailing address

4704 HOEN AVE
SANTA ROSA CA
95405-7824
US

V. Phone/Fax

Practice location:
  • Phone: 707-546-7979
  • Fax: 707-546-7667
Mailing address:
  • Phone: 707-546-7979
  • Fax: 707-546-7667

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. MICHAEL LONG TRAN
Title or Position: MEDICAL DIRECTOR/PRESIDENT
Credential: M.D.
Phone: 707-546-7979