Basic Information
| Provider Information | |||||||||
| NPI: | 1053368811 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MIDWEST PAIN MANAGEMENT, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5151 MORNING SUN RD | ||||||||
| Address2: | STE A | ||||||||
| City: | OXFORD | ||||||||
| State: | OH | ||||||||
| PostalCode: | 450569545 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5135245330 | ||||||||
| FaxNumber: | 5135245337 | ||||||||
| Practice Location | |||||||||
| Address1: | 5151 MORNING SUN RD | ||||||||
| Address2: | STE A | ||||||||
| City: | OXFORD | ||||||||
| State: | OH | ||||||||
| PostalCode: | 450569545 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5135245330 | ||||||||
| FaxNumber: | 5135245337 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/27/2006 | ||||||||
| LastUpdateDate: | 03/24/2014 | ||||||||
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| AuthorizedOfficialLastName: | ROSS | ||||||||
| AuthorizedOfficialFirstName: | WILLIAM | ||||||||
| AuthorizedOfficialMiddleName: | DOUGLAS | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 5135245330 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | DO | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine | 208VP0000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pain Medicine | Pain Medicine | 208VP0014X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pain Medicine | Interventional Pain Medicine |
ID Information
| ID | Type | State | Issuer | Description | 2978489 | 05 | OH | MEDICAID | DF1340 | 01 | OH | RR MEDICARE | OTHER | 200525610B | 05 | IN | MEDICAID | 200525610 A | 05 | IN | MEDICAID |