Healthcare Provider Details

I. General information

NPI: 1013280973
Provider Name (Legal Business Name): PAIN MANAGEMENT CENTERS OF ST. LOUIS, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/22/2012
Last Update Date: 02/22/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8045 BIG BEND BLVD SUITE 201
WEBSTER GROVES MO
63119-2714
US

IV. Provider business mailing address

8045 BIG BEND BLVD SUITE 201
WEBSTER GROVES MO
63119-2714
US

V. Phone/Fax

Practice location:
  • Phone: 314-374-3408
  • Fax:
Mailing address:
  • Phone: 314-374-3408
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number112767
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code2081P2900X
TaxonomyPain Medicine (Physical Medicine & Rehabilitation) Physician
License Number2007001540
License Number StateMO

VIII. Authorized Official

Name: DR. MITCHELL LIBERMAN
Title or Position: CEO
Credential: DC
Phone: 314-374-3408