1063971596 NPI number — SOUTHERN INTERVENTIONAL PAIN CENTER LLC

Table of content: (NPI 1063971596)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063971596 NPI number — SOUTHERN INTERVENTIONAL PAIN CENTER LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUTHERN INTERVENTIONAL PAIN CENTER LLC
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:
1063971596
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/31/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
615 S HANSELL ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
THOMASVILLE
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
31792-5556
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
229-226-2234
Provider Business Mailing Address Fax Number:
229-226-2237

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
619 SW BAYA DR STE 102
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAKE CITY
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32025-4204
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
386-361-3400
Provider Business Practice Location Address Fax Number:
855-313-1262
Provider Enumeration Date:
03/14/2019

Additional Information

Authorized Official

Authorized Official Last Name:
SHOKAT
Authorized Official First Name:
MAXIMILIAN
Authorized Official Middle Name:
SHAHRYAR
Authorized Official Title or Position:
MANAGING MEMBER
Authorized Official Telephone Number:
229-226-2234

Provider Taxonomy Codes

  • Taxonomy code: 2084N0400X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208VP0014X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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