Provider Demographics
NPI:1588715510
Name:ADVANCED PAIN MANAGEMENT
Entity type:Organization
Organization Name:ADVANCED PAIN MANAGEMENT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:W
Authorized Official - Last Name:NELSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:719-785-1161
Mailing Address - Street 1:1495 GARDEN OF THE GODS RD STE 102
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80907-3429
Mailing Address - Country:US
Mailing Address - Phone:719-591-0007
Mailing Address - Fax:719-260-9799
Practice Address - Street 1:1495 GARDEN OF THE GODS RD STE 102
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80907-3429
Practice Address - Country:US
Practice Address - Phone:719-591-0007
Practice Address - Fax:719-260-9799
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-16
Last Update Date:2008-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO36737174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO66791Medicare ID - Type UnspecifiedMEDICARE