Healthcare Provider Details

I. General information

NPI: 1750851390
Provider Name (Legal Business Name): PHILADELPHIA PAIN AND NEUROLOGY INSTITUTE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/27/2018
Last Update Date: 11/27/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1528 WALNUT STREET SUITE 620
PHILADELPHIA PA
19102
US

IV. Provider business mailing address

1528 WALNUT STREET SUITE 620
PHILADELPHIA PA
19102
US

V. Phone/Fax

Practice location:
  • Phone: 215-433-1575
  • Fax: 215-732-1649
Mailing address:
  • Phone: 215-433-1575
  • Fax: 215-732-1649

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. KEITH MICHAEL MILLER
Title or Position: PROVIDER
Credential: DC
Phone: 215-433-1575