Healthcare Provider Details

I. General information

NPI: 1942591722
Provider Name (Legal Business Name): MIDWEST CENTER FOR PAIN MANAGEMENT, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/27/2011
Last Update Date: 07/21/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

693 WAGNER AVE SUITE C
GREENVILLE OH
45331-2636
US

IV. Provider business mailing address

7986 TANNERS GATE LN
FLORENCE KY
41042-1863
US

V. Phone/Fax

Practice location:
  • Phone: 859-746-2444
  • Fax: 859-746-9666
Mailing address:
  • Phone: 859-746-2444
  • Fax: 859-746-9666

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: BRAD HAMBLEN
Title or Position: OWNER/ MEMBER
Credential:
Phone: 859-746-2444