Healthcare Provider Details

I. General information

NPI: 1891137220
Provider Name (Legal Business Name): INTERVENTIONAL PAIN CENTER, PLLC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/26/2013
Last Update Date: 06/17/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10653 WAYZATA BLVD SUITE 200
MINNETONKA MN
55305-1528
US

IV. Provider business mailing address

10653 WAYZATA BLVD SUITE 200
MINNETONKA MN
55305-1528
US

V. Phone/Fax

Practice location:
  • Phone: 952-236-7610
  • Fax: 952-426-0674
Mailing address:
  • Phone: 952-236-7610
  • Fax: 952-426-0674

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number3852
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number34220
License Number StateMN
# 3
Primary TaxonomyY
Taxonomy Code2081P2900X
TaxonomyPain Medicine (Physical Medicine & Rehabilitation) Physician
License Number44760
License Number StateMN
# 4
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number24316
License Number StateMN
# 5
Primary TaxonomyN
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number42871
License Number StateMN

VIII. Authorized Official

Name: DR. DAVID K KETROSER
Title or Position: OWNER
Credential: M.D.
Phone: 952-236-7610