Basic Information
| Provider Information | |||||||||
| NPI: | 1598297343 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PAIN MANAGEMENT ASSOCIATES | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8717 W 110TH ST | ||||||||
| Address2: | SUITE 600 | ||||||||
| City: | OVERLAND PARK | ||||||||
| State: | KS | ||||||||
| PostalCode: | 662102144 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9134282900 | ||||||||
| FaxNumber: | 9134282951 | ||||||||
| Practice Location | |||||||||
| Address1: | 10550 QUIVIRA RD | ||||||||
| Address2: | SUITE 270 | ||||||||
| City: | OVERLAND PARK | ||||||||
| State: | KS | ||||||||
| PostalCode: | 662152306 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8167631559 | ||||||||
| FaxNumber: | 8169658404 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/31/2017 | ||||||||
| LastUpdateDate: | 03/31/2017 | ||||||||
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| AuthorizedOfficialLastName: | GLENSKI | ||||||||
| AuthorizedOfficialFirstName: | JAMES | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT/CEO | ||||||||
| AuthorizedOfficialTelephone: | 9134282900 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208VP0000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pain Medicine | Pain Medicine |
ID Information
| ID | Type | State | Issuer | Description | 509679106 | 05 | MO | MEDICAID | H530000 | 01 | MO | MEDICARE | OTHER | CH6776 | 01 | MO | RR MEDICARE KCP | OTHER |