MEDICARE: WEST PHILADELPHIA PAIN MANAGEMENT CENTER

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	208100000X	Physical Medicine & Rehabilitation Physician	MD067744L	PA
2	111N00000X	Chiropractor	DC004566L	PA

General Provider Information

NPI Number	:	1396258380
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WEST PHILADELPHIA PAIN MANAGEMENT CENTER

Provider Business Mailing Address
First Line	:	600 LOUIS DR STE 202
Second Line	:
City	:	WARMINSTER
State	:	PA
Zip	:	18974-2847
Country	:	US
Telephone Number	:	215-957-5400
Fax Number	:	215-957-5401

Provider Business Practice Location Address
First Line	:	5429 CHESTNUT ST STE G19
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19139-3325
Country	:	US
Telephone Number	:	215-796-9003
Fax Number	:	215-596-0654

Authorized Official
Title or Position	:	OFFICE MANAGER
Name	:	SHARON KRISTOFF
Credential	:
Telephone Number	:	215-957-5400

Provider Enumeration Date	:	11/13/2017
Last Update Date	:	06/09/2022

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Directions to “WEST PHILADELPHIA PAIN MANAGEMENT CENTER ” Practice Location

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