Provider Demographics
NPI:1609351923
Name:INTERVENTIONAL PAIN MANAGEMENT
Entity type:Organization
Organization Name:INTERVENTIONAL PAIN MANAGEMENT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MAHENDRA
Authorized Official - Middle Name:
Authorized Official - Last Name:GUNAPOOTI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:314-830-2600
Mailing Address - Street 1:PO BOX 650
Mailing Address - Street 2:
Mailing Address - City:EDWARDSVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62025-0650
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2421 CORPORATE CTR STE 105
Practice Address - Street 2:
Practice Address - City:GRANITE CITY
Practice Address - State:IL
Practice Address - Zip Code:62040-4195
Practice Address - Country:US
Practice Address - Phone:618-288-8905
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-10-02
Last Update Date:2018-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies