Basic Information
Provider Information | |||||||||
NPI: | 1124087549 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | PAIN MANAGEMENT CENTER | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 3211 DUDLEY AVE | ||||||||
Address2: |   | ||||||||
City: | PARKERSBURG | ||||||||
State: | WV | ||||||||
PostalCode: | 261041813 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3044223904 | ||||||||
FaxNumber: | 3044223924 | ||||||||
Practice Location | |||||||||
Address1: | 600 18TH ST | ||||||||
Address2: |   | ||||||||
City: | PARKERSBURG | ||||||||
State: | WV | ||||||||
PostalCode: | 261013231 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3044224040 | ||||||||
FaxNumber: | 3044244022 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/23/2006 | ||||||||
LastUpdateDate: | 11/06/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | MATHENY | ||||||||
AuthorizedOfficialFirstName: | JEFFREY | ||||||||
AuthorizedOfficialMiddleName: | R | ||||||||
AuthorizedOfficialTitleorPosition: | TREASURER | ||||||||
AuthorizedOfficialTelephone: | 3044223904 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 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 | 0830220 | 05 | OH |   | MEDICAID | 0007055000 | 05 | WV |   | MEDICAID |