Healthcare Provider Details

I. General information

NPI: 1871050781
Provider Name (Legal Business Name): PAIN MANAGEMENT SOLUTION LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/27/2019
Last Update Date: 02/27/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4010 W GOELLER BLVD STE C
COLUMBUS IN
47201-8312
US

IV. Provider business mailing address

730 EXECUTIVE PARK DR STE A
GREENWOOD IN
46143-3213
US

V. Phone/Fax

Practice location:
  • Phone: 317-346-7246
  • Fax: 317-534-3763
Mailing address:
  • Phone: 317-346-7246
  • Fax: 317-534-3763

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: GREGORY SCOTT MASIMORE
Title or Position: AUTHORIZED OFFICIAL
Credential: MD
Phone: 317-346-7246