MEDICARE: PAIN MANAGEMENT PSYCHOLOGY SERVICES, PA

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	103T00000X	Psychologist	0388	NC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	616591400	OTHER		DOL/OWCP (DEPARTMENT OF LABOR OFFICE OF WORKERS COMPENSATION PROGRAMS)

General Provider Information

NPI Number	:	1255571410
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PAIN MANAGEMENT PSYCHOLOGY SERVICES, PA

Provider Business Mailing Address
First Line	:	160 KIMEL FOREST DR.
Second Line	:	STE. 100
City	:	WINSTON-SALEM
State	:	NC
Zip	:	27103-6084
Country	:	US
Telephone Number	:	336-770-6451
Fax Number	:	336-714-6475

Provider Business Practice Location Address
First Line	:	160 KIMEL FOREST DR.
Second Line	:	STE. 100
City	:	WINSTON-SALEM
State	:	NC
Zip	:	27103-6084
Country	:	US
Telephone Number	:	336-770-6451
Fax Number	:	336-714-6475

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. TIMOTHY NORRIS WEBSTER
Credential	:	PH.D.
Telephone Number	:	336-770-6451

Provider Enumeration Date	:	03/02/2009
Last Update Date	:	10/18/2013

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