=====================================================
General NPI Number Information
=====================================================
NPI Number | 1871905653
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MANSFIELD PAIN CLINIC LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/28/2014
-----------------------------------------------------
Last Update Date | 07/24/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 605 S TRIMBLE RD STE C
-----------------------------------------------------
City | MANSFIELD
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44906
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 646-535-5989
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 605 S TRIMBLE RD STE C
-----------------------------------------------------
City | MANSFIELD
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44906
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGER
-----------------------------------------------------
Name | MR. KASHIF ISHAQ
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 646-535-5989
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207LP2900X
-----------------------------------------------------
Taxonomy Name | Pain Medicine (Anesthesiology) Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------