Provider Demographics
NPI:1053690404
Name:PAIN MANAGEMENT PARTNERS LLC
Entity type:Organization
Organization Name:PAIN MANAGEMENT PARTNERS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CANDACE
Authorized Official - Middle Name:
Authorized Official - Last Name:MANGRUM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:314-275-8737
Mailing Address - Street 1:PO BOX 798348
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63179-8000
Mailing Address - Country:US
Mailing Address - Phone:314-275-8737
Mailing Address - Fax:314-205-1508
Practice Address - Street 1:3555 SUNSET OFFICE DR
Practice Address - Street 2:SUITE C110
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63127-1015
Practice Address - Country:US
Practice Address - Phone:314-909-8778
Practice Address - Fax:314-909-8777
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-16
Last Update Date:2012-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
No261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOMA2249Medicare PIN
MO6326800001Medicare NSC