Healthcare Provider Details

I. General information

NPI: 1518016823
Provider Name (Legal Business Name): PMCP, PSC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/09/2007
Last Update Date: 10/05/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2831 LONE OAK RD
PADUCAH KY
42003-8041
US

IV. Provider business mailing address

2831 LONE OAK RD
PADUCAH KY
42003-8041
US

V. Phone/Fax

Practice location:
  • Phone: 270-554-8373
  • Fax: 270-554-8987
Mailing address:
  • Phone: 270-554-8373
  • Fax: 270-554-8987

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number
License Number State

VIII. Authorized Official

Name: DR. LAXMAIAH MANCHIKANTI
Title or Position: CEO
Credential: M.D.
Phone: 270-554-8373