Healthcare Provider Details

I. General information

NPI: 1942357983
Provider Name (Legal Business Name): SOUTHEASTERN PAIN SPECIALISTS, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/04/2007
Last Update Date: 06/16/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1140 HAMMOND DRIVE D 4190
ATLANTA GA
30328-5331
US

IV. Provider business mailing address

1140 HAMMOND DRIVE D 4190
ATLANTA GA
30328-5331
US

V. Phone/Fax

Practice location:
  • Phone: 770-558-8501
  • Fax: 770-558-8512
Mailing address:
  • Phone: 770-558-8501
  • Fax: 770-558-8512

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. DONALD E KIRK
Title or Position: DIRECTOR
Credential:
Phone: 770-558-8501