Basic Information
| Provider Information | |||||||||
| NPI: | 1619968120 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CENTER FOR PAIN MANAGEMENT, SC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 13857 | ||||||||
| Address2: | |||||||||
| City: | WAUWATOSA | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532130857 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4144448670 | ||||||||
| FaxNumber: | 4144448678 | ||||||||
| Practice Location | |||||||||
| Address1: | 6200 W CENTER ST | ||||||||
| Address2: | |||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532102159 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4144448670 | ||||||||
| FaxNumber: | 4144448678 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/03/2005 | ||||||||
| LastUpdateDate: | 05/26/2017 | ||||||||
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| AuthorizedOfficialLastName: | HASAN | ||||||||
| AuthorizedOfficialFirstName: | NOSHEEN | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 4144448670 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | WI | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology | 208VP0014X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pain Medicine | Interventional Pain Medicine |
ID Information
| ID | Type | State | Issuer | Description | 21273400 | 05 | WI | MEDICAID |