Healthcare Provider Details

I. General information

NPI: 1497288971
Provider Name (Legal Business Name): INTERVENTIONAL CENTER FOR PAIN
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/11/2017
Last Update Date: 04/11/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5203 CHIPPEWA ST SUITE 301
SAINT LOUIS MO
63109-2356
US

IV. Provider business mailing address

5203 CHIPPEWA ST SUITE 301
SAINT LOUIS MO
63109-2356
US

V. Phone/Fax

Practice location:
  • Phone: 314-481-5000
  • Fax: 314-481-3037
Mailing address:
  • Phone: 314-481-5000
  • Fax: 314-481-3037

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code364SA2200X
TaxonomyAdult Health Clinical Nurse Specialist
License Number2016043827
License Number StateMO

VIII. Authorized Official

Name: DR. GURPREET S PADDA
Title or Position: MEDICAL DIRECTOR
Credential: M.D
Phone: 314-481-5000