Basic Information
| Provider Information | |||||||||
| NPI: | 1871729723 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PROFESSIONAL PHYSICIAN PAIN SERVICES, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4400 WILL ROGERS PKWY | ||||||||
| Address2: | SUITE 105 | ||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731081837 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4059475557 | ||||||||
| FaxNumber: | 4059486507 | ||||||||
| Practice Location | |||||||||
| Address1: | 114 PIPER HILL DR | ||||||||
| Address2: | SUITE 103 | ||||||||
| City: | SAINT PETERS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 633761661 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6364425035 | ||||||||
| FaxNumber: | 6364425036 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/05/2009 | ||||||||
| LastUpdateDate: | 06/30/2009 | ||||||||
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| AuthorizedOfficialLastName: | NEAL | ||||||||
| AuthorizedOfficialFirstName: | DEBORAH | ||||||||
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| AuthorizedOfficialTitleorPosition: | COORDINATOR | ||||||||
| AuthorizedOfficialTelephone: | 4059475557 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207LP2900X | 2006018031 | MO | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology | Pain Medicine | 207LP2900X | 2004009978 | MO | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology | Pain Medicine |
No ID Information.