Basic Information
| Provider Information | |||||||||
| NPI: | 1619233079 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ADVANCED PAIN MEDICINE PC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | ADVANCED PAIN MEDICINE MOON | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 7000 STONEWOOD DR | ||||||||
| Address2: | STE 151 | ||||||||
| City: | WEXFORD | ||||||||
| State: | PA | ||||||||
| PostalCode: | 150907376 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1009 BEAVER GRADE RD | ||||||||
| Address2: | STE 100 | ||||||||
| City: | MOON TWP | ||||||||
| State: | PA | ||||||||
| PostalCode: | 151082969 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7249330300 | ||||||||
| FaxNumber: | 7249330456 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/10/2012 | ||||||||
| LastUpdateDate: | 08/24/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | LODICO | ||||||||
| AuthorizedOfficialFirstName: | MARK | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | MEDICAL DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 7249330300 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 08/24/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 0077653000002 | 05 | PA | MEDICAID |