Healthcare Provider Details

I. General information

NPI: 1548214182
Provider Name (Legal Business Name): PAIN CARE INSTITUTE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/19/2006
Last Update Date: 12/15/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6200 FRANKFORD AVE
PHILADELPHIA PA
19135-3400
US

IV. Provider business mailing address

6200 FRANKFORD AVE
PHILADELPHIA PA
19135-3400
US

V. Phone/Fax

Practice location:
  • Phone: 215-535-3980
  • Fax: 215-535-5025
Mailing address:
  • Phone: 215-535-3980
  • Fax: 215-535-5025

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License NumberMD045589L
License Number StatePA

VIII. Authorized Official

Name: MS. TRACEY A EVERHAM
Title or Position: OFFICE MANAGER
Credential:
Phone: 215-338-1811