Healthcare Provider Details

I. General information

NPI: 1619968120
Provider Name (Legal Business Name): CENTER FOR PAIN MANAGEMENT, SC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/03/2005
Last Update Date: 05/26/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6200 W CENTER ST
MILWAUKEE WI
53210-2159
US

IV. Provider business mailing address

PO BOX 13857
WAUWATOSA WI
53213-0857
US

V. Phone/Fax

Practice location:
  • Phone: 414-444-8670
  • Fax: 414-444-8678
Mailing address:
  • Phone: 414-444-8670
  • Fax: 414-444-8678

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: NOSHEEN HASAN
Title or Position: OWNER
Credential: MD
Phone: 414-444-8670