Healthcare Provider Details

I. General information

NPI: 1295827665
Provider Name (Legal Business Name): PAIN TREATMENT CENTER INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/29/2006
Last Update Date: 04/05/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2821 N BALLAS RD SUITE C-11
SAINT LOUIS MO
63131-2321
US

IV. Provider business mailing address

PO BOX 953010
ST LOUIS MO
63195-3010
US

V. Phone/Fax

Practice location:
  • Phone: 314-872-5601
  • Fax: 314-872-5628
Mailing address:
  • Phone: 314-872-5601
  • Fax: 314-872-5628

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number036092540
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number109904
License Number StateMO

VIII. Authorized Official

Name: DR. JOHN DAVID GRAHAM
Title or Position: OWNER PRESIDENT
Credential: MD
Phone: 314-872-5601