Healthcare Provider Details

I. General information

NPI: 1811220304
Provider Name (Legal Business Name): ADVANCED PAIN MANAGEMENT, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/15/2009
Last Update Date: 10/26/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

620 S 400 E STE 201
ST GEORGE UT
84770-7060
US

IV. Provider business mailing address

620 S 400 E STE 201
ST GEORGE UT
84770-7060
US

V. Phone/Fax

Practice location:
  • Phone: 435-656-0029
  • Fax: 435-656-9144
Mailing address:
  • Phone: 435-656-0029
  • Fax: 435-656-9144

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number5566449-1205
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License Number5566449-1205
License Number StateUT
# 3
Primary TaxonomyN
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number5566449-1205
License Number StateUT

VIII. Authorized Official

Name: DR. ALEXEY A RYSKIN
Title or Position: OWNER
Credential: MD
Phone: 435-656-0029