Basic Information
| Provider Information | |||||||||
| NPI: | 1609269653 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PM&R PAIN FREE, LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| OtherOrganizationName: | SPINE MUSCLES NERVES | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 19645 PROGRESS DR | ||||||||
| Address2: | |||||||||
| City: | STRONGSVILLE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441493205 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4402348833 | ||||||||
| FaxNumber: | 4402343313 | ||||||||
| Practice Location | |||||||||
| Address1: | 450 ALKYRE RUN STE 360 | ||||||||
| Address2: | |||||||||
| City: | WESTERVILLE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 430826914 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6149189808 | ||||||||
| FaxNumber: | 6149189807 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/16/2015 | ||||||||
| LastUpdateDate: | 05/05/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | GOULD | ||||||||
| AuthorizedOfficialFirstName: | ROBERT | ||||||||
| AuthorizedOfficialMiddleName: | E. | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 6149189808 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | D.O. | ||||||||
| NPICertificationDate: | 05/05/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208VP0000X | 34009895 | OH | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pain Medicine | Pain Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0121242 GROUP | 05 | OH | MEDICAID |