Basic Information
| Provider Information | |||||||||
| NPI: | 1023172798 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | OHIO VALLEY ANESTHESIA PAIN MANAGEMENT INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 49 | ||||||||
| Address2: | |||||||||
| City: | PITTSBURGH | ||||||||
| State: | PA | ||||||||
| PostalCode: | 152300049 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4129375700 | ||||||||
| FaxNumber: | 4129375739 | ||||||||
| Practice Location | |||||||||
| Address1: | 500 PINE HOLLOW RD | ||||||||
| Address2: | |||||||||
| City: | MC KEES ROCKS | ||||||||
| State: | PA | ||||||||
| PostalCode: | 151361683 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4127776400 | ||||||||
| FaxNumber: | 4127776376 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/20/2006 | ||||||||
| LastUpdateDate: | 11/27/2007 | ||||||||
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| AuthorizedOfficialLastName: | PROVENZANO | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 4129375944 | ||||||||
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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 | 208VP0000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pain Medicine | Pain Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1017878770001 | 05 | PA | MEDICAID | 1920241 | 01 | PA | BLUE SHIELD | OTHER |