NPIMap

Organization Active NPI

Pro Pain LLC

  • Pain Medicine (Anesthesiology) Physician
  • Fenton, MO
National Provider Identifier
1205339074
Registry record updated Dec 6, 2018
On this page

Key facts

NPPES NPI Registry
Primary specialty
Pain Medicine (Anesthesiology) PhysicianTaxonomy code 207LP2900X
Legal business name
PRO PAIN LLC
Practice address
1055 Bowles Ave Ste 202
Fenton, MO 63026-2308
Phone
(636) 326-7821
NPI assigned
Mar 17, 2018
Last updated
Dec 6, 2018By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Dec 6, 2018

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

Authorized official

Name
Mr. Michael Boedefeld, MDNPI 1043299548
Title
Owner
Phone
(636) 442-5035

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Pain Medicine (Anesthesiology) Physician 207LP2900X NU Primary

Addresses

Primary practice location

1055 Bowles Ave Ste 202
Fenton, MO 63026-2308

Mailing address

4800 Mexico Rd Ste 101
Saint Peters, MO 63376-1666
Phone (636) 442-5035

Other practice location 1

4800 Mexico Rd
Saint Peters, MO 63376
Phone (636) 442-5036

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in MO2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20180419001389 MO Part B Supplier - Clinic/Group Practice 0941563225 Receives reassigned benefits from 8 practitioners
Practice locations: Fenton, MO; Saint Peters, MO
O20190130000208 MO DME Supplier - Physician - Interventional Pain Management 0941563225 Practice locations: Fenton, MO

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

Locations

4800 Mexico Rd
Saint Peters, MO 63376
Phone (636) 442-5036

Practitioners & affiliated clinicians

Practitioners 10

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

NPI Registry JSON

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

{
    "created_epoch": "1521244800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1544054400000",
    "number": "1205339074",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "4800 MEXICO RD STE 101",
            "city": "SAINT PETERS",
            "state": "MO",
            "postal_code": "633761666",
            "telephone_number": "636-442-5035"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1055 BOWLES AVE STE 202",
            "city": "FENTON",
            "state": "MO",
            "postal_code": "630262308",
            "telephone_number": "636-326-7821"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "4800 Mexico Rd",
            "address_purpose": "LOCATION",
            "city": "Saint Peters",
            "state": "MO",
            "postal_code": "63376",
            "country_code": "US",
            "telephone_number": "636-442-5036",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "organization_name": "PRO PAIN LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2018-03-17",
        "last_updated": "2018-12-06",
        "status": "A",
        "authorized_official_last_name": "BOEDEFELD",
        "authorized_official_first_name": "MICHAEL",
        "authorized_official_title_or_position": "OWNER",
        "authorized_official_telephone_number": "636-442-5035",
        "authorized_official_name_prefix": "Mr.",
        "authorized_official_credential": "MD"
    },
    "taxonomies": [
        {
            "code": "207LP2900X",
            "taxonomy_group": "",
            "desc": "Anesthesiology, Pain Medicine",
            "state": "NU",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Fenton, MO

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Dec 6, 2018; 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.