Healthcare Provider Details

I. General information

NPI: 1609351923
Provider Name (Legal Business Name): INTERVENTIONAL PAIN MANAGEMENT SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/02/2018
Last Update Date: 05/06/2026
Certification Date: 05/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2421 CORPORATE CTR STE 105
GRANITE CITY IL
62040-4195
US

IV. Provider business mailing address

PO BOX 650
EDWARDSVILLE IL
62025-0650
US

V. Phone/Fax

Practice location:
  • Phone: 618-288-8905
  • Fax:
Mailing address:
  • Phone: 314-830-2600
  • Fax: 314-830-2648

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: MAHENDRA GUNAPOOTI
Title or Position: PRESIDENT
Credential: MD
Phone: 314-830-2600