1255820502 NPI number — GEORGIA PAIN AND SPINE SOLUTIONS, PC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1255820502 NPI number — GEORGIA PAIN AND SPINE SOLUTIONS, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GEORGIA PAIN AND SPINE SOLUTIONS, PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1255820502
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/28/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
07/19/2019
NPI Reactivation Date:
07/26/2019

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
P.O. BOX 370160
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DECATUR
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30037-0160
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
404-403-4567
Provider Business Mailing Address Fax Number:
404-920-8185

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
76 HIGHLAND PAVILION COURT
Provider Second Line Business Practice Location Address:
#133
Provider Business Practice Location Address City Name:
HIRAM
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30141-3170
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
800-533-8210
Provider Business Practice Location Address Fax Number:
404-745-8013
Provider Enumeration Date:
05/02/2018

Additional Information

Authorized Official

Authorized Official Last Name:
POLK
Authorized Official First Name:
MARCUS
Authorized Official Middle Name:
Q
Authorized Official Title or Position:
PRESIDENT/CEO
Authorized Official Telephone Number:
404-403-4567

Provider Taxonomy Codes

  • Taxonomy code: 207LP2900X , with the licence number:  040758 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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