MEDICARE: INTERVENTIONAL PAIN MANAGEMENT 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

General Provider Information

NPI Number	:	1497898621
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	INTERVENTIONAL PAIN MANAGEMENT PC

Provider Business Mailing Address
First Line	:	9015 ARBOR ST
Second Line	:	#155
City	:	OMAHA
State	:	NE
Zip	:	68124-2056
Country	:	US
Telephone Number	:	402-384-2600
Fax Number	:	402-384-2606

Provider Business Practice Location Address
First Line	:	9015 ARBOR ST
Second Line	:	#155
City	:	OMAHA
State	:	NE
Zip	:	68124-2056
Country	:	US
Telephone Number	:	402-384-2600
Fax Number	:	402-384-2606

Authorized Official
Title or Position	:	PRESIDENT
Name	:	SHAWN J PETTIS
Credential	:	M.D.
Telephone Number	:	402-384-2600

Provider Enumeration Date	:	02/15/2007
Last Update Date	:	08/22/2020

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