MEDICARE: HAVERFORT PAIN MANAGEMENT LLC

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	261Q00000X	Clinic/Center

General Provider Information

NPI Number	:	1780915603
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HAVERFORT PAIN MANAGEMENT LLC

Provider Business Mailing Address
First Line	:	7592 HAVERPORT AVE
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19151-0000
Country	:	US
Telephone Number	:	267-934-4040
Fax Number	:

Provider Business Practice Location Address
First Line	:	7592 HAVERFORT AVE
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19151-2113
Country	:	US
Telephone Number	:	267-934-4040
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	ANDREW POLNET
Credential	:
Telephone Number	:	267-934-4040

Provider Enumeration Date	:	01/15/2010
Last Update Date	:	01/28/2010

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