Healthcare Provider Details

I. General information

NPI: 1124087549
Provider Name (Legal Business Name): PAIN MANAGEMENT CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/23/2006
Last Update Date: 11/06/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 18TH ST
PARKERSBURG WV
26101-3231
US

IV. Provider business mailing address

3211 DUDLEY AVE
PARKERSBURG WV
26104-1813
US

V. Phone/Fax

Practice location:
  • Phone: 304-422-4040
  • Fax: 304-424-4022
Mailing address:
  • Phone: 304-422-3904
  • Fax: 304-422-3924

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: JEFFREY R MATHENY
Title or Position: TREASURER
Credential:
Phone: 304-422-3904