Provider Demographics
NPI:1134215247
Name:ST LOUIS PAIN MANAGEMENT CENTER INC
Entity type:Organization
Organization Name:ST LOUIS PAIN MANAGEMENT CENTER INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ACCT MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KIM
Authorized Official - Middle Name:
Authorized Official - Last Name:DEBOLD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:314-432-2580
Mailing Address - Street 1:PO BOX 1209
Mailing Address - Street 2:
Mailing Address - City:MARYLAND HEIGHTS
Mailing Address - State:MO
Mailing Address - Zip Code:63043-0209
Mailing Address - Country:US
Mailing Address - Phone:314-432-2580
Mailing Address - Fax:314-432-0223
Practice Address - Street 1:11605 STUDT AVE
Practice Address - Street 2:SUITE 120
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141-7052
Practice Address - Country:US
Practice Address - Phone:314-432-2580
Practice Address - Fax:314-569-3162
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-05
Last Update Date:2013-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO000014227Medicare ID - Type Unspecified