Basic Information
| Provider Information | |||||||||
| NPI: | 1003901976 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | LAKE OF THE OZARKS PAIN MANAGEMENT SERVICES, INC | ||||||||
| LastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 5151 OSAGE BEACH PKWY STE F | ||||||||
| Address2: | PO BOX 840 | ||||||||
| City: | OSAGE BEACH | ||||||||
| State: | MO | ||||||||
| PostalCode: | 650653285 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5733021661 | ||||||||
| FaxNumber: | 5733021719 | ||||||||
| Practice Location | |||||||||
| Address1: | 54 HOSPITAL DR | ||||||||
| Address2: | |||||||||
| City: | OSAGE BEACH | ||||||||
| State: | MO | ||||||||
| PostalCode: | 650653050 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5733021661 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/04/2006 | ||||||||
| LastUpdateDate: | 05/25/2012 | ||||||||
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| AuthorizedOfficialLastName: | MEAD | ||||||||
| AuthorizedOfficialFirstName: | ALAN | ||||||||
| AuthorizedOfficialMiddleName: | W | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 5733021661 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 508901402 | 05 | MO | MEDICAID |