Basic Information
| Provider Information | |||||||||
| NPI: | 1174700975 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PREMIER PAIN MANAGEMENT, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4540 E BASELINE RD STE 105 | ||||||||
| Address2: | |||||||||
| City: | MESA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852064616 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4802728944 | ||||||||
| FaxNumber: | 4802375682 | ||||||||
| Practice Location | |||||||||
| Address1: | 4540 E BASELINE RD STE 112 | ||||||||
| Address2: | |||||||||
| City: | MESA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852064616 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4802728944 | ||||||||
| FaxNumber: | 4802375682 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/24/2008 | ||||||||
| LastUpdateDate: | 10/28/2010 | ||||||||
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| AuthorizedOfficialLastName: | SIEFFERT | ||||||||
| AuthorizedOfficialFirstName: | JAMES | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CLINICAL ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 2802728944 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | DC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP3300X | OTC4333 | AZ | Y | Ambulatory Health Care Facilities | Clinic/Center | Pain |
ID Information
| ID | Type | State | Issuer | Description | OTC4913 | 01 | AZ | OTC LICENSCE | OTHER |