Healthcare Provider Details

I. General information

NPI: 1336631456
Provider Name (Legal Business Name): WORCESTER PAIN MANAGEMENT PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/04/2018
Last Update Date: 06/28/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

116 BELMONT ST RM 34
WORCESTER MA
01605
US

IV. Provider business mailing address

1 CARLISLE TER
NATICK MA
01760-2060
US

V. Phone/Fax

Practice location:
  • Phone: 508-904-9026
  • Fax:
Mailing address:
  • Phone: 508-904-9026
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: DEMIAN G MOUSAD
Title or Position: OWNER
Credential: MD
Phone: 508-904-9026