Basic Information
| Provider Information | |||||||||
| NPI: | 1336386465 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ADVANCED PAIN ASSOCIATES LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | P.O. BOX 39179 | ||||||||
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| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 85069 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6023950718 | ||||||||
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| Practice Location | |||||||||
| Address1: | 5102 W CAMPBELL AVE | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850311703 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6022671779 | ||||||||
| FaxNumber: | 6022778146 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/12/2009 | ||||||||
| LastUpdateDate: | 02/20/2009 | ||||||||
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| AuthorizedOfficialLastName: | DIGGES | ||||||||
| AuthorizedOfficialFirstName: | LESLIE | ||||||||
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| AuthorizedOfficialTitleorPosition: | OFFICE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 6023950718 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208VP0000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pain Medicine | Pain Medicine |
ID Information
| ID | Type | State | Issuer | Description | 552465 | 05 | AZ | MEDICAID |