MEDICARE: WARREN PAIN CLINIC AND ACUPUNCTURE CENTER, PC

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	207LP2900X	Pain Medicine (Anesthesiology) Physician	MD049485L	PA

General Provider Information

NPI Number	:	1255352241
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WARREN PAIN CLINIC AND ACUPUNCTURE CENTER, PC

Provider Business Mailing Address
First Line	:	908 NIAGARA FALLS BLVD
Second Line	:	SUITE 208
City	:	NORTH TONAWANDA
State	:	NY
Zip	:	14120-2019
Country	:	US
Telephone Number	:	716-692-2160
Fax Number	:	716-213-0935

Provider Business Practice Location Address
First Line	:	103 WEST ST. CLAIR STREET
Second Line	:	SUITE 2C
City	:	WARREN
State	:	PA
Zip	:	16365-2188
Country	:	US
Telephone Number	:	814-726-7365
Fax Number	:	814-726-7369

Authorized Official
Title or Position	:	PHYSICIAN/OWNER
Name	:	DR. MOHAMED KOURTU
Credential	:	MD
Telephone Number	:	814-726-7365

Provider Enumeration Date	:	07/22/2006
Last Update Date	:	04/24/2014

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