Healthcare Provider Details

I. General information

NPI: 1003123746
Provider Name (Legal Business Name): PARTNERS IN PAIN MANAGEMENT, MSO, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/01/2010
Last Update Date: 09/01/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1033 CHAMPIONS WAY STE 100
SUFFOLK VA
23435-3761
US

IV. Provider business mailing address

1080 ESTATES CT
PORTSMOUTH VA
23703-5465
US

V. Phone/Fax

Practice location:
  • Phone: 757-646-3798
  • Fax:
Mailing address:
  • Phone: 757-646-3798
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP3300X
TaxonomyPain Clinic/Center
License Number0102050102
License Number StateVA

VIII. Authorized Official

Name: MS. ULLA B PEDERSEN
Title or Position: MANAGING PARTNER
Credential:
Phone: 757-646-3798