Healthcare Provider Details

I. General information

NPI: 1811072143
Provider Name (Legal Business Name): ST LOUIS PAIN MANAGEMENT CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/26/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

777 N NEW BALLAS RD
ST LOUIS MO
63141
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: 314-432-0223
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: LYNN HENDERSON
Title or Position: ACCT MANAGER
Credential:
Phone: 314-432-2580