=====================================================
General NPI Number Information
=====================================================
NPI Number | 1528512530
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | OFFICE BASED PAIN SOLUTIONS, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/08/2016
-----------------------------------------------------
Last Update Date | 08/08/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9400 MCKNIGHT RD SUITE 103
-----------------------------------------------------
City | PITTSBURGH
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 15237-6007
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 412-837-1156
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9400 MCKNIGHT RD SUITE 103
-----------------------------------------------------
City | PITTSBURGH
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 15237-6007
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 412-837-1156
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. BENJAMIN JAGIELLO
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 412-837-1156
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208VP0000X
-----------------------------------------------------
Taxonomy Name | Pain Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------