1750494423 NPI number — GEORGIA PAIN SPINE CENTER

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 1750494423 NPI number — GEORGIA PAIN SPINE CENTER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GEORGIA PAIN SPINE CENTER
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:
1750494423
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/20/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 11407 DEPT 2657
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BIRMINGHAM
Provider Business Mailing Address State Name:
AL
Provider Business Mailing Address Postal Code:
35246-0001
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
770-920-4950
Provider Business Mailing Address Fax Number:
770-929-9092

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
15 MEDICAL DRIVE
Provider Second Line Business Practice Location Address:
SUITE 302
Provider Business Practice Location Address City Name:
CARTERSVILLE
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30121
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
678-337-3163
Provider Business Practice Location Address Fax Number:
770-422-7306
Provider Enumeration Date:
08/16/2006

Additional Information

Authorized Official

Authorized Official Last Name:
BECK
Authorized Official First Name:
VICTORIA
Authorized Official Middle Name:
Authorized Official Title or Position:
CFO
Authorized Official Telephone Number:
404-403-8310

Provider Taxonomy Codes

  • Taxonomy code: 261QP3300X , with the licence number:  008-311 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QA1903X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 5665923 . This is a "CCN AND FIRST HEALTH" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".




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