Basic Information
| Provider Information | |||||||||
| NPI: | 1447270228 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NORTHERN PAIN MGM CTR | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 10417 | ||||||||
| Address2: | |||||||||
| City: | HOLYOKE | ||||||||
| State: | MA | ||||||||
| PostalCode: | 010412017 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4135400150 | ||||||||
| FaxNumber: | 4135400159 | ||||||||
| Practice Location | |||||||||
| Address1: | 125 LIBERTY ST | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | SPRINGFIELD | ||||||||
| State: | MA | ||||||||
| PostalCode: | 011031114 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4137337515 | ||||||||
| FaxNumber: | 4137337371 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/21/2006 | ||||||||
| LastUpdateDate: | 04/07/2008 | ||||||||
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| AuthorizedOfficialLastName: | OGOKE | ||||||||
| AuthorizedOfficialFirstName: | BENTLEY | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 4137337515 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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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 | 9787666 | 05 | MA | MEDICAID | M16992 | 01 | MA | BCBS | OTHER |