Healthcare Provider Details

I. General information

NPI: 1871729723
Provider Name (Legal Business Name): PROFESSIONAL PHYSICIAN PAIN SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/05/2009
Last Update Date: 06/30/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

114 PIPER HILL DR SUITE 103
SAINT PETERS MO
63376-1661
US

IV. Provider business mailing address

4400 WILL ROGERS PKWY SUITE 105
OKLAHOMA CITY OK
73108-1837
US

V. Phone/Fax

Practice location:
  • Phone: 636-442-5035
  • Fax: 636-442-5036
Mailing address:
  • Phone: 405-947-5557
  • Fax: 405-948-6507

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number2006018031
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number2004009978
License Number StateMO

VIII. Authorized Official

Name: DEBORAH NEAL
Title or Position: COORDINATOR
Credential:
Phone: 405-947-5557