Basic Information
| Provider Information | |||||||||
| NPI: | 1003299181 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | COMPREHENSIVE PAIN TREATMENT LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10111 E 21ST ST N STE 106 | ||||||||
| Address2: | |||||||||
| City: | WICHITA | ||||||||
| State: | KS | ||||||||
| PostalCode: | 672063555 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3163517687 | ||||||||
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| Practice Location | |||||||||
| Address1: | 10111 E 21ST ST N | ||||||||
| Address2: | SUITE 106 | ||||||||
| City: | WICHITA | ||||||||
| State: | KS | ||||||||
| PostalCode: | 672063508 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3163517687 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/07/2015 | ||||||||
| LastUpdateDate: | 02/16/2021 | ||||||||
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| AuthorizedOfficialLastName: | AIN | ||||||||
| AuthorizedOfficialFirstName: | ROBERT | ||||||||
| AuthorizedOfficialMiddleName: | JASON | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3163712827 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 02/16/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207LP2900X | 04-29063 | KS | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology | Pain Medicine |
ID Information
| ID | Type | State | Issuer | Description | 100394170B | 05 | KS | MEDICAID |