Basic Information
Provider Information | |||||||||
NPI: | 1871985788 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | PAIN MANAGEMENT RESOURCES INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 5800 MONROE ST | ||||||||
Address2: | BLDG E SUITE 4 | ||||||||
City: | SYLVANIA | ||||||||
State: | OH | ||||||||
PostalCode: | 435602263 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4198245063 | ||||||||
FaxNumber: | 4198240216 | ||||||||
Practice Location | |||||||||
Address1: | 5800 MONROE ST | ||||||||
Address2: | BLDG E SUITE 4 | ||||||||
City: | SYLVANIA | ||||||||
State: | OH | ||||||||
PostalCode: | 435602263 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4198245063 | ||||||||
FaxNumber: | 4198240216 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/02/2015 | ||||||||
LastUpdateDate: | 03/10/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | ABOU-CHAKRA | ||||||||
AuthorizedOfficialFirstName: | IMAN | ||||||||
AuthorizedOfficialMiddleName: | S | ||||||||
AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
AuthorizedOfficialTelephone: | 4198245063 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | DR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | MD | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208100000X | 35083590 | OH | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation |   |
No ID Information.