Provider Demographics
NPI:1487980660
Name:PROFESSIONAL PHYSICIANS PAIN SERVICES, LLC
Entity type:Organization
Organization Name:PROFESSIONAL PHYSICIANS PAIN SERVICES, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:SCOTT
Authorized Official - Last Name:BOEDEFELD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:314-729-7100
Mailing Address - Street 1:PO BOX 31434
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63131-0434
Mailing Address - Country:US
Mailing Address - Phone:314-729-7100
Mailing Address - Fax:314-729-0292
Practice Address - Street 1:10012 KENNERLY RD
Practice Address - Street 2:SUITE 404
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63128-2197
Practice Address - Country:US
Practice Address - Phone:314-729-7100
Practice Address - Fax:314-729-0292
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-10-23
Last Update Date:2009-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOF62832Medicare UPIN
MOI58101Medicare UPIN
MOI28749Medicare UPIN