1518012004 NPI number — INTERVENTIONAL SPINE AND PAIN MANAGEMENT CENTER, 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 1518012004 NPI number — INTERVENTIONAL SPINE AND PAIN MANAGEMENT CENTER, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
INTERVENTIONAL SPINE AND PAIN MANAGEMENT CENTER, 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:
ALLIANCE SPINE AND PAIN CENTERS
Provider Other Organization Name Type Code:
3
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:
1518012004
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/03/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3390 PEACHTREE RD NE
Provider Second Line Business Mailing Address:
SUITE 1500
Provider Business Mailing Address City Name:
ATLANTA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30326-1157
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
770-929-9033
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1388 WELLBROOK CIR NE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CONYERS
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30012-3872
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
404-920-4950
Provider Business Practice Location Address Fax Number:
404-920-4959
Provider Enumeration Date:
01/24/2007

Additional Information

Authorized Official

Authorized Official Last Name:
FOWLER
Authorized Official First Name:
ROBIN
Authorized Official Middle Name:
J
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
770-929-9033

Provider Taxonomy Codes

  • Taxonomy code: 174400000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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