Basic Information
| Provider Information | |||||||||
| NPI: | 1871772004 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | INSTITUTE OF PAIN MANAGEMENT, P.C. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3328 N CLASSEN BLVD | ||||||||
| Address2: | |||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731183428 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4055245200 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3328 N CLASSEN BLVD | ||||||||
| Address2: | |||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731183428 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4055245200 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/24/2007 | ||||||||
| LastUpdateDate: | 12/13/2010 | ||||||||
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| AuthorizedOfficialLastName: | TRANG | ||||||||
| AuthorizedOfficialFirstName: | LIEM | ||||||||
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| AuthorizedOfficialTitleorPosition: | C.E.O. / PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 4055245200 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | D.O. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207LP2900X | 3429 | OK | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology | Pain Medicine |
ID Information
| ID | Type | State | Issuer | Description | 100125970B | 05 | OK | MEDICAID |