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General NPI Number Information
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NPI Number | 1114171519
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Entity Type | Organization
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Legal Business Name | ADVANCED PAIN MANAGEMENT PLLC
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Dates
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Enumeration Date | 11/11/2008
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Last Update Date | 11/23/2011
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Provider Practice Location Address
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Address Line | 2275 SO EAGLE RD SUTE 160
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City | MERIDIAN
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State | ID
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Zip | 83642
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Country | US
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Telephone | 208-947-2266
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Fax | 208-947-2267
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Provider Business Mailing Address
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Address Line | 6140 CURTISIAN AVE SUITE 400
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City | BOISE
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State | ID
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Zip | 83704-8880
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Country | US
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Telephone | 208-327-5600
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Fax | 208-367-2968
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Authorized Official
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Title or Position | MEMBER
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Name | MICHAEL DALE SEVERSON
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Credential | MD
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Telephone | 208-880-9464
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207LP2900X
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Taxonomy Name | Pain Medicine (Anesthesiology) Physician
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License Number |
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License Number State |
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