Provider Demographics
NPI:1124087549
Name:PAIN MANAGEMENT CENTER
Entity type:Organization
Organization Name:PAIN MANAGEMENT CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:TREASURER
Authorized Official - Prefix:
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:R
Authorized Official - Last Name:MATHENY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:304-422-3904
Mailing Address - Street 1:3211 DUDLEY AVE
Mailing Address - Street 2:
Mailing Address - City:PARKERSBURG
Mailing Address - State:WV
Mailing Address - Zip Code:26104-1813
Mailing Address - Country:US
Mailing Address - Phone:304-422-3904
Mailing Address - Fax:304-422-3924
Practice Address - Street 1:600 18TH ST
Practice Address - Street 2:
Practice Address - City:PARKERSBURG
Practice Address - State:WV
Practice Address - Zip Code:26101-3231
Practice Address - Country:US
Practice Address - Phone:304-422-4040
Practice Address - Fax:304-424-4022
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-23
Last Update Date:2007-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain MedicineGroup - Multi-Specialty
No208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0830220Medicaid
WV0007055000Medicaid
OH0830220Medicaid
WV9932231Medicare PIN
WV0007055000Medicaid