Healthcare Provider Details

I. General information

NPI: 1962825497
Provider Name (Legal Business Name): PREMIER INTERVENTIONAL PAIN OF DELAWARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/04/2014
Last Update Date: 02/05/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

701 N CLAYTON ST
WILMINGTON DE
19805-3165
US

IV. Provider business mailing address

2655 NORTHWINDS PKWY
ALPHARETTA GA
30009-2280
US

V. Phone/Fax

Practice location:
  • Phone: 770-643-5501
  • Fax: 404-941-1304
Mailing address:
  • Phone: 770-643-5501
  • Fax: 404-941-1304

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code367H00000X
TaxonomyAnesthesiologist Assistant
License Number
License Number State
# 7
Primary TaxonomyY
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: KERRY TEEL
Title or Position: PRESIDENT
Credential:
Phone: 770-643-5501