=====================================================
General NPI Number Information
=====================================================
NPI Number | 1154375848
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PAIN MEDICINE SPECIALISTS, PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/19/2006
-----------------------------------------------------
Last Update Date | 03/25/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1300 HORIZON DR SUITE 101
-----------------------------------------------------
City | CHALFONT
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 18914-3970
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 215-712-2545
-----------------------------------------------------
Fax | 215-712-2540
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1300 HORIZON DR SUITE 101
-----------------------------------------------------
City | CHALFONT
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 18914-3970
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 215-712-2545
-----------------------------------------------------
Fax | 215-712-2540
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | WILLIAM EARL GUSA JR.
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 215-712-2545
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207LP2900X
-----------------------------------------------------
Taxonomy Name | Pain Medicine (Anesthesiology) Physician
-----------------------------------------------------
License Number | MD052249L
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------