MEDICARE: PAIN MANAGEMENT REHABILITATION 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	207LP2900X	Pain Medicine (Anesthesiology) Physician	2006031936	MO

General Provider Information

NPI Number	:	1831468446
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PAIN MANAGEMENT REHABILITATION LLC

Provider Business Mailing Address
First Line	:	103 CHURCH ST
Second Line	:
City	:	O FALLON
State	:	MO
Zip	:	63366-2894
Country	:	US
Telephone Number	:	636-294-6322
Fax Number	:	636-294-6323

Provider Business Practice Location Address
First Line	:	103 CHURCH ST
Second Line	:
City	:	O FALLON
State	:	MO
Zip	:	63366-2894
Country	:	US
Telephone Number	:	636-294-6322
Fax Number	:	636-294-6323

Authorized Official
Title or Position	:	PHYSICIAN
Name	:	DR. DALE JOSEPH KLEIN
Credential	:	M.D.
Telephone Number	:	636-294-6322

Provider Enumeration Date	:	12/28/2011
Last Update Date	:	01/09/2012

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