Healthcare Provider Details

I. General information

NPI: 1558989277
Provider Name (Legal Business Name): INTERVENTIONAL PAIN GROUP PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/09/2020
Last Update Date: 08/02/2022
Certification Date: 03/03/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1004 PROGRESS DR STE 170
LANSING KS
66043-6323
US

IV. Provider business mailing address

PO BOX 269
LANSING KS
66043-0269
US

V. Phone/Fax

Practice location:
  • Phone: 913-828-0136
  • Fax: 913-828-0296
Mailing address:
  • Phone: 913-828-0136
  • Fax: 913-828-0296

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0000X
TaxonomyPain Management Registered Nurse
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QP3300X
TaxonomyPain Clinic/Center
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code261QR0200X
TaxonomyRadiology Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: VIKKI LEIGH GAMBRILL
Title or Position: PRESIDENT
Credential: CRNA
Phone: 913-717-0177