Organization
PAIN TREATMENT CENTER INC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DR. JOHN DAVID GRAHAM MD (OWNER PRESIDENT)
(314) 872-5601
Entity
Organization
Contact information
Practice address
2821 N BALLAS RD, SUITE C-11, SAINT LOUIS, MO 63131-2321
(314) 872-5601
(314) 872-5628
Mailing address
PO BOX 953010, ST LOUIS, MO 63195-3010
(314) 872-5601
(314) 872-5628
Taxonomy
Speciality
Code
Description
License number
State
207LP2900X
Pain Medicine (Anesthesiology) Physician
036092540
IL
207LP2900X
Pain Medicine (Anesthesiology) Physician
Primary
109904
MO
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
0004669135
AETNA
—
01
—
050065227
RR MEDICARE
—
01
—
114762
BCBS
MO
01
—
115491
MERCY
—
01
—
2000288
UNITED HEATHCARE
—
01
—
28931
CMR
MO
01
—
28931
GHP ASO LHI
—
01
—
30087
GHP
—
01
—
322628
HEALTHLINK
—
01
—
514766005
TRICARE NORTH WEST
—
Enumeration date
09/29/2006
Last updated
04/05/2010
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