NPIMap

Organization Active NPI

Interventional Pain & Physical Medicine Clinic

  • Pain Clinic/Center
  • Sartell, MN
National Provider Identifier
1013056969
Registry record updated Jul 14, 2015
On this page

Key facts

NPPES NPI Registry
Primary specialty
Pain Clinic/CenterTaxonomy code 261QP3300X
License
41961 Issued in MN
Legal business name
INTERVENTIONAL PAIN & PHYSICAL MEDICINE CLINIC
Practice address
2301 Connecticut Avenue South
Sartell, MN 56377-2474
Phone
(320) 229-1500
Fax
(320) 229-1505
NPI assigned
Feb 6, 2007
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jul 14, 2015

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Mrs. Stacy Kowalkowski, R.N.
Title
Administrator
Phone
(320) 229-1500

Specialties & licenses 4

Specialty (taxonomy)CodeLicenseStatePrimary
Physical Medicine & Rehabilitation PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 208100000X 41961 MN
Interventional Pain Medicine PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 208VP0014X 41961 MN
Physical Therapy Clinic/Center 261QP2000X 41961 MN
Pain Clinic/Center 261QP3300X 41961 MN Primary

Addresses

Primary practice location

2301 Connecticut Avenue South
Sartell, MN 56377-2474

Mailing address

2301 Connecticut Avenue South
Sartell, MN 56377-2474
Phone (320) 229-1500

Other identifiers 2

IdentifierTypeStateIssuer
410645800MedicaidMN
C03449OtherMNMEDICARE PTAN

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in MN

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20040223000665 MN Part B Supplier - Clinic/Group Practice 3375439953 Receives reassigned benefits from 8 practitioners
Practice locations: Sartell, MN

Other NPIs with the same Medicare PAC ID 1

NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).

National Provider Directory

National Provider Directory
Tax ID family
Interventional Pain Physic4 organizations share this tax ID, including this one

Other organizations with this tax ID 3

Organizations that report the same tax identification number in the National Provider Directory.

Practitioners & affiliated clinicians

Practitioners 9

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1170720000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1436832000000",
    "number": "1013056969",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "2301 CONNECTICUT AVENUE SOUTH",
            "city": "SARTELL",
            "state": "MN",
            "postal_code": "563772474",
            "telephone_number": "320-229-1500",
            "fax_number": "320-229-1505"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "2301 CONNECTICUT AVENUE SOUTH",
            "city": "SARTELL",
            "state": "MN",
            "postal_code": "563772474",
            "telephone_number": "320-229-1500",
            "fax_number": "320-229-1505"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "INTERVENTIONAL PAIN & PHYSICAL MEDICINE CLINIC",
        "organizational_subpart": "NO",
        "enumeration_date": "2007-02-06",
        "last_updated": "2015-07-14",
        "status": "A",
        "authorized_official_last_name": "KOWALKOWSKI",
        "authorized_official_first_name": "STACY",
        "authorized_official_title_or_position": "ADMINISTRATOR",
        "authorized_official_telephone_number": "320-229-1500",
        "authorized_official_name_prefix": "Mrs.",
        "authorized_official_credential": "R.N."
    },
    "taxonomies": [
        {
            "code": "208100000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Physical Medicine & Rehabilitation",
            "state": "MN",
            "license": "41961",
            "primary": false
        },
        {
            "code": "208VP0014X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Pain Medicine, Interventional Pain Medicine",
            "state": "MN",
            "license": "41961",
            "primary": false
        },
        {
            "code": "261QP2000X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Physical Therapy",
            "state": "MN",
            "license": "41961",
            "primary": false
        },
        {
            "code": "261QP3300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Pain",
            "state": "MN",
            "license": "41961",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "410645800",
            "state": "MN"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "MEDICARE PTAN",
            "identifier": "C03449",
            "state": "MN"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Sartell, MN

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 14, 2015; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.