=====================================================
General NPI Number Information
=====================================================
NPI Number | 1871042432
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PRIME MEDICAL PAIN MANAGEMENT CENTERS II PLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/23/2016
-----------------------------------------------------
Last Update Date | 12/14/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4527 N 27TH AVE
-----------------------------------------------------
City | PHOENIX
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85017-3702
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 602-300-4754
-----------------------------------------------------
Fax | 602-249-1614
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4527 N 27TH AVE
-----------------------------------------------------
City | PHOENIX
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85017-3702
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 602-300-4754
-----------------------------------------------------
Fax | 602-249-1614
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PARTNER
-----------------------------------------------------
Name | ROGER BAKER
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 602-300-4754
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP3300X
-----------------------------------------------------
Taxonomy Name | Pain Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------