Provider Demographics
NPI:1669585428
Name:CLEVELAND BACK & PAIN MANAGEMENT CENTER INC.
Entity type:Organization
Organization Name:CLEVELAND BACK & PAIN MANAGEMENT CENTER INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR/ OFFICER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:HARVEY
Authorized Official - Last Name:NICKELS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:216-687-4003
Mailing Address - Street 1:2307 W 14TH ST
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44113-3612
Mailing Address - Country:US
Mailing Address - Phone:216-687-4003
Mailing Address - Fax:216-687-4069
Practice Address - Street 1:2307 W 14TH ST
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44113-3612
Practice Address - Country:US
Practice Address - Phone:216-687-4003
Practice Address - Fax:216-687-4069
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-16
Last Update Date:2012-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35051581207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2802695Medicaid
OHCO3399Medicare UPIN
OHCL9934101Medicare PIN