MEDICARE: INNOVATIVE PAIN CENTER LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208VP0014X	Interventional Pain Medicine Physician	0425	SD

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	73M96IN	OTHER	MN	BCBS
2	4995163	OTHER	SD	BCBS
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1003851163
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	INNOVATIVE PAIN CENTER LLC

Provider Business Mailing Address
First Line	:	1201 MICKELSON DR STE 2
Second Line	:
City	:	WATERTOWN
State	:	SD
Zip	:	57201-7253
Country	:	US
Telephone Number	:	605-882-0432
Fax Number	:	605-882-0978

Provider Business Practice Location Address
First Line	:	1512 4TH ST NE
Second Line	:
City	:	WATERTOWN
State	:	SD
Zip	:	57201-6824
Country	:	US
Telephone Number	:	605-884-0100
Fax Number	:

Authorized Official
Title or Position	:	PROVIDER
Name	:	PATRICK L RETTERATH
Credential	:	MD
Telephone Number	:	605-884-0100

Provider Enumeration Date	:	06/20/2006
Last Update Date	:	12/22/2010

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