=====================================================
General NPI Number Information
=====================================================
NPI Number | 1790226595
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PRIME PAIN SPECIALISTS LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/13/2017
-----------------------------------------------------
Last Update Date | 03/13/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 301 S 7TH ST SUITE 310
-----------------------------------------------------
City | READING
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19602-2432
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 610-568-5078
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 301 S 7TH ST SUITE 310
-----------------------------------------------------
City | READING
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19602-2432
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 610-568-5078
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | AKINTOMI OLUGBODI
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 610-568-5078
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208VP0000X
-----------------------------------------------------
Taxonomy Name | Pain Medicine Physician
-----------------------------------------------------
License Number | MD446378
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------