Basic Information
| Provider Information | |||||||||
| NPI: | 1942470687 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MILLENNIUM PAIN MANAGEMENT, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 13131 TESSON FERRY RD | ||||||||
| Address2: | SUITE #105 | ||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631283887 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3147568035 | ||||||||
| FaxNumber: | 3147568050 | ||||||||
| Practice Location | |||||||||
| Address1: | 13131 TESSON FERRY RD | ||||||||
| Address2: | SUITE #105 | ||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631283887 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3147568035 | ||||||||
| FaxNumber: | 3147568050 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/10/2008 | ||||||||
| LastUpdateDate: | 01/08/2009 | ||||||||
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| AuthorizedOfficialLastName: | COLEMAN | ||||||||
| AuthorizedOfficialFirstName: | KEVIN | ||||||||
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| AuthorizedOfficialTitleorPosition: | PHYSICIAN | ||||||||
| AuthorizedOfficialTelephone: | 3147568035 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208VP0014X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pain Medicine | Interventional Pain Medicine |
No ID Information.