Healthcare Provider Details

I. General information

NPI: 1356630792
Provider Name (Legal Business Name): PHENIX CITY PAIN MANAGEMENT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/06/2011
Last Update Date: 10/23/2023
Certification Date: 10/23/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1810 STADIUM DR STE 140
PHENIX CITY AL
36867-3178
US

IV. Provider business mailing address

1810 STADIUM DR
PHENIX CITY AL
36867-3177
US

V. Phone/Fax

Practice location:
  • Phone: 334-214-4616
  • Fax: 334-214-4618
Mailing address:
  • Phone: 334-664-1969
  • Fax: 888-391-2191

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License Number26975
License Number StateAL

VIII. Authorized Official

Name: DR. BILL GENE BERRYMAN
Title or Position: PHYSICIAN
Credential: MD
Phone: 334-214-4616