MEDICARE: INTERVENTIONAL PAIN MANAGEMENT SERVICES 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	332B00000X	Durable Medical Equipment & Medical Supplies

General Provider Information

NPI Number	:	1043795354
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	INTERVENTIONAL PAIN MANAGEMENT SERVICES LLC

Provider Business Mailing Address
First Line	:	PO BOX 650
Second Line	:
City	:	EDWARDSVILLE
State	:	IL
Zip	:	62025-0650
Country	:	US
Telephone Number	:	314-830-2600
Fax Number	:	314-830-2648

Provider Business Practice Location Address
First Line	:	2421 CORPORATE CTR STE 105
Second Line	:
City	:	GRANITE CITY
State	:	IL
Zip	:	62040-4195
Country	:	US
Telephone Number	:	314-830-2600
Fax Number	:	314-830-2648

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MAHENDRA GUNAPOOTI
Credential	:	MD
Telephone Number	:	314-830-2600

Provider Enumeration Date	:	10/02/2018
Last Update Date	:	05/14/2026

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