Basic Information
| Provider Information | |||||||||
| NPI: | 1093828584 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | COLUMBIA INTERVENTIONAL PAIN CENTER LLP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 7237 | ||||||||
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| City: | COLUMBIA | ||||||||
| State: | MO | ||||||||
| PostalCode: | 652057237 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5734686501 | ||||||||
| FaxNumber: | 5734686502 | ||||||||
| Practice Location | |||||||||
| Address1: | 305 N KEENE ST | ||||||||
| Address2: | SUITE #105 | ||||||||
| City: | COLUMBIA | ||||||||
| State: | MO | ||||||||
| PostalCode: | 652016897 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5734422299 | ||||||||
| FaxNumber: | 5734423196 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/17/2006 | ||||||||
| LastUpdateDate: | 09/24/2014 | ||||||||
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| AuthorizedOfficialLastName: | MESTON | ||||||||
| AuthorizedOfficialFirstName: | JULIA | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 5734422299 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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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 |
ID Information
| ID | Type | State | Issuer | Description | 507608008 | 05 | MO | MEDICAID |