MEDICARE: SOUTH PHILADELPHIA PAIN MANAGEMENT

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	208D00000X	General Practice Physician

General Provider Information

NPI Number	:	1790994838
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUTH PHILADELPHIA PAIN MANAGEMENT

Provider Business Mailing Address
First Line	:	PO BOX 1006
Second Line	:
City	:	BENSALEM
State	:	PA
Zip	:	19020-5006
Country	:	US
Telephone Number	:	215-755-7595
Fax Number	:	215-755-7608

Provider Business Practice Location Address
First Line	:	1732 S BROAD ST
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19145-2321
Country	:	US
Telephone Number	:	215-755-7595
Fax Number	:	215-755-7608

Authorized Official
Title or Position	:	BILLING
Name	:	MINDY GUSS
Credential	:
Telephone Number	:	215-750-9600

Provider Enumeration Date	:	05/22/2007
Last Update Date	:	05/08/2009

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