MEDICARE: INTERVENTIONAL SPINE AND PAIN MANAGEMENT CENTER, PC

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	208VP0014X	Interventional Pain Medicine Physician

General Provider Information

NPI Number	:	1861077315
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	INTERVENTIONAL SPINE AND PAIN MANAGEMENT CENTER, PC

Provider Business Mailing Address
First Line	:	3390 PEACHTREE RD NE STE 1500
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30326-2822
Country	:	US
Telephone Number	:	404-920-4950
Fax Number	:

Provider Business Practice Location Address
First Line	:	3685 BRASELTON HWY STE 100
Second Line	:
City	:	DACULA
State	:	GA
Zip	:	30019-5920
Country	:	US
Telephone Number	:	404-920-4950
Fax Number	:

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

Provider Enumeration Date	:	03/16/2021
Last Update Date	:	03/16/2021

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