MEDICARE: ADVANCED PAIN MANAGEMENT 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	207LP2900X	Pain Medicine (Anesthesiology) Physician

General Provider Information

NPI Number	:	1639413347
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ADVANCED PAIN MANAGEMENT PA

Provider Business Mailing Address
First Line	:	3604 SADDLE RIDGE
Second Line	:
City	:	INDEPENDENCE
State	:	MO
Zip	:	64057-2332
Country	:	US
Telephone Number	:	913-302-2703
Fax Number	:

Provider Business Practice Location Address
First Line	:	C/O CENTERPOINT MEDICAL CENTER
Second Line	:	19550 E 39TH ST, STE 110
City	:	INDEPENDENCE
State	:	MO
Zip	:	64057-2353
Country	:	US
Telephone Number	:	816-698-8900
Fax Number	:	816-698-8905

Authorized Official
Title or Position	:	PRACTICE ADMINISTRATOR
Name	:	SHIRLEY DEHARDT
Credential	:
Telephone Number	:	913-302-2703

Provider Enumeration Date	:	11/19/2012
Last Update Date	:	09/28/2021

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