Healthcare Provider Details

I. General information

NPI: 1073665584
Provider Name (Legal Business Name): PAIN MANAGEMENT CARE PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/17/2007
Last Update Date: 11/18/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2106 IRONWOOD CIR
SOUTH BEND IN
46635-1864
US

IV. Provider business mailing address

2106 IRONWOOD CIR
SOUTH BEND IN
46635-1864
US

V. Phone/Fax

Practice location:
  • Phone: 574-247-4682
  • Fax: 574-247-4685
Mailing address:
  • Phone: 574-247-4682
  • Fax: 574-247-4685

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number01024859B
License Number StateIN

VIII. Authorized Official

Name: DR. JOSEPH G GLAZIER
Title or Position: OWNER
Credential: MD
Phone: 574-273-6546