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General NPI Number Information
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NPI Number | 1295827665
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Entity Type | Organization
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Legal Business Name | PAIN TREATMENT CENTER INC
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Dates
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Enumeration Date | 09/29/2006
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Last Update Date | 04/05/2010
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Provider Practice Location Address
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Address Line | 2821 N BALLAS RD SUITE C-11
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City | SAINT LOUIS
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State | MO
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Zip | 63131-2321
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Country | US
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Telephone | 314-872-5601
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Fax | 314-872-5628
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Provider Business Mailing Address
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Address Line | PO BOX 953010
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City | ST LOUIS
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State | MO
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Zip | 63195-3010
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Country | US
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Telephone | 314-872-5601
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Fax | 314-872-5628
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Authorized Official
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Title or Position | OWNER PRESIDENT
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Name | DR. JOHN DAVID GRAHAM
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Credential | MD
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Telephone | 314-872-5601
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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 | 036092540
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License Number State | IL
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Taxonomy #2
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Taxonomy Code | 207LP2900X
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Taxonomy Name | Pain Medicine (Anesthesiology) Physician
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License Number | 109904
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License Number State | MO
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