Basic Information
| Provider Information | |||||||||
| NPI: | 1902805948 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | UT CENTER FOR PAIN MANAGEMENT AND RESEARCH, INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | NEXUS PAIN CARE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3585 N UNIVERSITY AVE STE 150 | ||||||||
| Address2: | |||||||||
| City: | PROVO | ||||||||
| State: | UT | ||||||||
| PostalCode: | 846046630 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8013566100 | ||||||||
| FaxNumber: | 8013562113 | ||||||||
| Practice Location | |||||||||
| Address1: | 3585 N UNIVERSITY AVE STE 150 | ||||||||
| Address2: | |||||||||
| City: | PROVO | ||||||||
| State: | UT | ||||||||
| PostalCode: | 846046630 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8013566100 | ||||||||
| FaxNumber: | 8013562113 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/20/2005 | ||||||||
| LastUpdateDate: | 09/30/2014 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | ROSENTHAL | ||||||||
| AuthorizedOfficialFirstName: | RICHARD | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | MEDICAL DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 8013566100 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208100000X | 43731 | UT | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | 103T00000X | 43731 | UT | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | 208VP0000X | 43731 | UT | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pain Medicine | Pain Medicine |
No ID Information.