Healthcare Provider Details

I. General information

NPI: 1134215247
Provider Name (Legal Business Name): ST LOUIS PAIN MANAGEMENT CENTER INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/05/2006
Last Update Date: 11/18/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11605 STUDT AVE SUITE 120
SAINT LOUIS MO
63141-7052
US

IV. Provider business mailing address

PO BOX 1209
MARYLAND HEIGHTS MO
63043-0209
US

V. Phone/Fax

Practice location:
  • Phone: 314-432-2580
  • Fax: 314-569-3162
Mailing address:
  • Phone: 314-432-2580
  • Fax: 314-432-0223

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: KIM DEBOLD
Title or Position: ACCT MANAGER
Credential:
Phone: 314-432-2580