Basic Information
| Provider Information | |||||||||
| NPI: | 1063993103 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PREMIER PAIN CENTERS, LLC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11350 MCCORMICK RD | ||||||||
| Address2: | EXECUTIVE PLAZA 1, STE. 501 | ||||||||
| City: | HUNT VALLEY | ||||||||
| State: | MD | ||||||||
| PostalCode: | 21031 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4103291071 | ||||||||
| FaxNumber: | 4103291054 | ||||||||
| Practice Location | |||||||||
| Address1: | 150 CHAMBERS BRIDGE RD STE 201 | ||||||||
| Address2: | |||||||||
| City: | BRICK | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 087233491 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7324580322 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/27/2018 | ||||||||
| LastUpdateDate: | 08/27/2018 | ||||||||
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| AuthorizedOfficialLastName: | O'HARA | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | WILLIAM | ||||||||
| AuthorizedOfficialTitleorPosition: | DO | ||||||||
| AuthorizedOfficialTelephone: | 7323800200 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208VP0014X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pain Medicine | Interventional Pain Medicine |
No ID Information.