MEDICARE: CONSULTANTS IN PAIN MEDICINE,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	207LP2900X	Pain Medicine (Anesthesiology) Physician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	6400190001	OTHER	GA	DME PTAN

General Provider Information

NPI Number	:	1417265570
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CONSULTANTS IN PAIN MEDICINE,LLC

Provider Business Mailing Address
First Line	:	3221 GLYNN AVE
Second Line	:
City	:	BRUNSWICK
State	:	GA
Zip	:	31520-4851
Country	:	US
Telephone Number	:	912-466-9111
Fax Number	:	912-466-0366

Provider Business Practice Location Address
First Line	:	303 HARRIS INDUSTRIAL BLVD
Second Line	:
City	:	VIDALIA
State	:	GA
Zip	:	30474-8853
Country	:	US
Telephone Number	:	912-537-4414
Fax Number	:	912-537-4437

Authorized Official
Title or Position	:	OWNER
Name	:	DR. THOMAS E RUNYAN
Credential	:	M.D.
Telephone Number	:	912-466-9111

Provider Enumeration Date	:	09/22/2010
Last Update Date	:	04/18/2011

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