Healthcare Provider Details

I. General information

NPI: 1235756792
Provider Name (Legal Business Name): INTERVENTIONAL SPINE AND PAIN MANAGEMENT CENTER, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/01/2020
Last Update Date: 07/01/2020
Certification Date: 07/01/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2100 CENTRAL AVE STE 6
AUGUSTA GA
30904-6709
US

IV. Provider business mailing address

3390 PEACHTREE RD NE STE 1500
ATLANTA GA
30326-2822
US

V. Phone/Fax

Practice location:
  • Phone: 404-920-4950
  • Fax:
Mailing address:
  • Phone: 404-920-4950
  • Fax:

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: VICTORIA BECK
Title or Position: CFO
Credential:
Phone: 404-920-4950