MEDICARE: GEORGIA INTERVENTIONAL PAIN - Q, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QA1903X	Ambulatory Surgical Clinic/Center

General Provider Information

NPI Number	:	1164274601
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GEORGIA INTERVENTIONAL PAIN - Q, LLC

Provider Business Mailing Address
First Line	:	455 PHILIP BLVD STE 140
Second Line	:
City	:	LAWRENCEVILLE
State	:	GA
Zip	:	30046-8768
Country	:	US
Telephone Number	:	770-962-3642
Fax Number	:	770-962-3643

Provider Business Practice Location Address
First Line	:	5670 OLD WINDER HWY STE 104
Second Line	:
City	:	BRASELTON
State	:	GA
Zip	:	30517-1239
Country	:	US
Telephone Number	:	770-962-3642
Fax Number	:	770-962-3643

Authorized Official
Title or Position	:	CEO
Name	:	AMIT S PATEL
Credential	:	MD
Telephone Number	:	770-962-3642

Provider Enumeration Date	:	04/05/2024
Last Update Date	:	04/05/2024

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