1255820502 NPI number — GEORGIA PAIN AND SPINE SOLUTIONS, PC

Table of content: (NPI 1255820502)

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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