Basic Information
| Provider Information | |||||||||
| NPI: | 1881936029 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PAIN MANAGEMENT ASSOCIATES OF GLASTONBURY LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 318 FELDSPAR RDG | ||||||||
| Address2: | |||||||||
| City: | GLASTONBURY | ||||||||
| State: | CT | ||||||||
| PostalCode: | 060333391 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8607590060 | ||||||||
| FaxNumber: | 8606336041 | ||||||||
| Practice Location | |||||||||
| Address1: | 394 W CENTER ST | ||||||||
| Address2: | |||||||||
| City: | MANCHESTER | ||||||||
| State: | CT | ||||||||
| PostalCode: | 060404735 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8607590060 | ||||||||
| FaxNumber: | 8606336041 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/26/2013 | ||||||||
| LastUpdateDate: | 03/26/2013 | ||||||||
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| AuthorizedOfficialLastName: | GASZEK | ||||||||
| AuthorizedOfficialFirstName: | EWA | ||||||||
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| AuthorizedOfficialTitleorPosition: | CREDENTIALING SUPERVISOR | ||||||||
| AuthorizedOfficialTelephone: | 8602824137 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | CT | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology | 207LP2900X | CT | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology | Pain Medicine |
No ID Information.