Healthcare Provider Details

I. General information

NPI: 1457435281
Provider Name (Legal Business Name): COMPREHENSIVE PAIN MANAGEMENT, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/25/2006
Last Update Date: 01/12/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3870 MEDICAL PARK DRIVE
AUSTELL GA
30106-1110
US

IV. Provider business mailing address

P.O. BOX 629
AUSTELL GA
30168-1006
US

V. Phone/Fax

Practice location:
  • Phone: 770-948-6824
  • Fax: 770-948-6804
Mailing address:
  • Phone: 770-948-6824
  • Fax: 770-948-6804

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: JAIMINI A DAVE
Title or Position: PRESIDENT
Credential: MD
Phone: 770-948-6824