Basic Information
| Provider Information | |||||||||
| NPI: | 1003851163 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | INNOVATIVE PAIN CENTER LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1201 MICKELSON DR STE 2 | ||||||||
| Address2: | |||||||||
| City: | WATERTOWN | ||||||||
| State: | SD | ||||||||
| PostalCode: | 572017253 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6058820432 | ||||||||
| FaxNumber: | 6058820978 | ||||||||
| Practice Location | |||||||||
| Address1: | 1512 4TH ST NE | ||||||||
| Address2: | |||||||||
| City: | WATERTOWN | ||||||||
| State: | SD | ||||||||
| PostalCode: | 572016824 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6058840100 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/20/2006 | ||||||||
| LastUpdateDate: | 12/22/2010 | ||||||||
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| AuthorizedOfficialLastName: | RETTERATH | ||||||||
| AuthorizedOfficialFirstName: | PATRICK | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | PROVIDER | ||||||||
| AuthorizedOfficialTelephone: | 6058840100 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208VP0014X | 0425 | SD | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pain Medicine | Interventional Pain Medicine |
ID Information
| ID | Type | State | Issuer | Description | 73M96IN | 01 | MN | BCBS | OTHER | 4995163 | 01 | SD | BCBS | OTHER | 892980000 | 05 | MN | MEDICAID |