1568003481 NPI number — INTERVENTIONAL PAIN INSTITUTE LLC

Table of content: (NPI 1568003481)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1568003481 NPI number — INTERVENTIONAL PAIN INSTITUTE LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
INTERVENTIONAL PAIN INSTITUTE 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:
1568003481
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/20/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
11/04/2022
NPI Reactivation Date:
12/20/2022

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2800 OLD DAWSON ROAD
Provider Second Line Business Mailing Address:
SUITE 2, BOX 245
Provider Business Mailing Address City Name:
ALBANY
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
31707
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
229-405-2470
Provider Business Mailing Address Fax Number:
229-405-2473

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3200 GILLIONVILLE RD STE 100
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ALBANY
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
31721-2815
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
229-405-2470
Provider Business Practice Location Address Fax Number:
229-405-2473
Provider Enumeration Date:
10/02/2019

Additional Information

Authorized Official

Authorized Official Last Name:
FUSSELL
Authorized Official First Name:
WILLIE
Authorized Official Middle Name:
MICHAEL
Authorized Official Title or Position:
PHYSICIAN/OWNER
Authorized Official Telephone Number:
229-405-2470

Provider Taxonomy Codes

  • 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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