Healthcare Provider Details

I. General information

NPI: 1548059835
Provider Name (Legal Business Name): SOUTHERN PAIN AND SPINE ASSOCIATES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/02/2025
Last Update Date: 12/16/2025
Certification Date: 12/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1150 HAMMOND DR STE 50
ATLANTA GA
30328-7500
US

IV. Provider business mailing address

1233 HIGHWAY 54 W STE 207
FAYETTEVILLE GA
30214-4643
US

V. Phone/Fax

Practice location:
  • Phone: 678-971-4167
  • Fax: 833-989-2501
Mailing address:
  • Phone: 678-971-4167
  • Fax: 833-989-2501

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: JOSEPHINE EVANGELISTA
Title or Position: CREDENTIALING MANAGER
Credential:
Phone: 404-408-2144