MEDICARE: UPPER VALLEY PAIN CLINIC 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	208VP0000X	Pain Medicine Physician

General Provider Information

NPI Number	:	1144438029
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	UPPER VALLEY PAIN CLINIC LLC

Provider Business Mailing Address
First Line	:	180 S STANFIELD RD
Second Line	:	SUITE B
City	:	TROY
State	:	OH
Zip	:	45373-0106
Country	:	US
Telephone Number	:	937-440-9758
Fax Number	:

Provider Business Practice Location Address
First Line	:	180 S STANFIELD RD
Second Line	:	SUITE B
City	:	TROY
State	:	OH
Zip	:	45373-0106
Country	:	US
Telephone Number	:	937-440-9758
Fax Number	:

Authorized Official
Title or Position	:	MD/OWNER
Name	:	DR. EASAW THOMAS
Credential	:	M.D.
Telephone Number	:	937-440-9758

Provider Enumeration Date	:	05/21/2007
Last Update Date	:	11/03/2016

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