Provider Demographics
NPI:1124613732
Name:INTEGRATIVE PAIN MANAGEMENT SC
Entity type:Organization
Organization Name:INTEGRATIVE PAIN MANAGEMENT SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:JOSEPH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:920-532-9117
Mailing Address - Street 1:3108 MID VALLEY DR
Mailing Address - Street 2:
Mailing Address - City:DE PERE
Mailing Address - State:WI
Mailing Address - Zip Code:54115-9436
Mailing Address - Country:US
Mailing Address - Phone:920-532-9117
Mailing Address - Fax:
Practice Address - Street 1:3108 MID VALLEY DR
Practice Address - Street 2:
Practice Address - City:DE PERE
Practice Address - State:WI
Practice Address - Zip Code:54115-9436
Practice Address - Country:US
Practice Address - Phone:920-532-9117
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:INTEGRATIVE PAIN MANAGEMENT, SC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2021-03-05
Last Update Date:2021-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Multi-Specialty