Healthcare Provider Details

I. General information

NPI: 1679514087
Provider Name (Legal Business Name): PAIN MANAGEMENT PHYSICIANS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/09/2006
Last Update Date: 03/15/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1601 E BROADWAY LOWER LEVEL
COLUMBIA MO
65201
US

IV. Provider business mailing address

PO BOX 7096
STOCKTON CA
95267
US

V. Phone/Fax

Practice location:
  • Phone: 573-815-2700
  • Fax: 573-815-3693
Mailing address:
  • Phone: 209-956-7725
  • Fax: 209-956-7733

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number
License Number State

VIII. Authorized Official

Name: STEVEN STREET
Title or Position: PARTNER
Credential: DO
Phone: 573-815-2700