Healthcare Provider Details

I. General information

NPI: 1356840409
Provider Name (Legal Business Name): ADVANCED PAIN MANAGEMENT GROUP, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/05/2018
Last Update Date: 02/05/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4063 SALISBURY RD STE 100
JACKSONVILLE FL
32216-6199
US

IV. Provider business mailing address

PO BOX 16421
GREENVILLE SC
29606-7421
US

V. Phone/Fax

Practice location:
  • Phone: 904-256-4573
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. GEETHA MANCHIREDDY
Title or Position: MEDICAL DIRECTOR
Credential: MD
Phone: 678-565-9444