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General NPI Number Information
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NPI Number | 1124459276
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Entity Type | Organization
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Legal Business Name | FW INTERVENTIONAL PAIN MANAGEMENT LLC
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Dates
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Enumeration Date | 11/27/2013
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Last Update Date | 02/18/2014
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Provider Practice Location Address
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Address Line | 2510 E DUPONT RD SUITE 115
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City | FORT WAYNE
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State | IN
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Zip | 46825-1600
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Country | US
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Telephone | 260-672-8979
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Fax |
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Provider Business Mailing Address
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Address Line | 2510 E DUPONT RD SUITE 115
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City | FORT WAYNE
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State | IN
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Zip | 46825-1600
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Country | US
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Telephone | 260-672-8979
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Fax |
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Authorized Official
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Title or Position | SOLE MEMBER
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Name | DR. MICHAEL COZZI
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Credential | MD
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Telephone | 260-672-8979
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207L00000X
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Taxonomy Name | Anesthesiology Physician
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License Number | 01045203A
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License Number State | IN
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