Basic Information
| Provider Information | |||||||||
| NPI: | 1841591211 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | COMPREHENSIVE PAIN MANAGEMENT SPECIALISTS LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1177 HIGHWAY 315 BLVD | ||||||||
| Address2: | DOLPHIN PLAZA | ||||||||
| City: | WILKES BARRE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 187026928 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5702705713 | ||||||||
| FaxNumber: | 5702705719 | ||||||||
| Practice Location | |||||||||
| Address1: | 1177 HIGHWAY 315 BLVD | ||||||||
| Address2: | DOLPHIN PLAZA | ||||||||
| City: | WILKES BARRE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 187026928 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5702705713 | ||||||||
| FaxNumber: | 5702705719 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/16/2010 | ||||||||
| LastUpdateDate: | 10/03/2012 | ||||||||
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| AuthorizedOfficialLastName: | PAZ | ||||||||
| AuthorizedOfficialFirstName: | JOSEPH | ||||||||
| AuthorizedOfficialMiddleName: | D | ||||||||
| AuthorizedOfficialTitleorPosition: | SOLE MEMBER | ||||||||
| AuthorizedOfficialTelephone: | 5702705713 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | D.O. | ||||||||
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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 | 1025631710001 | 05 | PA | MEDICAID | 2576567 | 01 | PA | BLUE SHIELD | OTHER |