Healthcare Provider Details

I. General information

NPI: 1396258380
Provider Name (Legal Business Name): WEST PHILADELPHIA PAIN MANAGEMENT CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/13/2017
Last Update Date: 06/09/2022
Certification Date: 06/09/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5429 CHESTNUT ST STE G19
PHILADELPHIA PA
19139-3325
US

IV. Provider business mailing address

600 LOUIS DR STE 202
WARMINSTER PA
18974-2847
US

V. Phone/Fax

Practice location:
  • Phone: 215-796-9003
  • Fax: 215-596-0654
Mailing address:
  • Phone: 215-957-5400
  • Fax: 215-957-5401

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License NumberMD067744L
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberDC004566L
License Number StatePA

VIII. Authorized Official

Name: SHARON KRISTOFF
Title or Position: OFFICE MANAGER
Credential:
Phone: 215-957-5400