Healthcare Provider Details

I. General information

NPI: 1396053286
Provider Name (Legal Business Name): MD PAIN CARE PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/14/2010
Last Update Date: 02/26/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1301 SIGMAN RD NE SUITE 100
CONYERS GA
30012-3812
US

IV. Provider business mailing address

1301 SIGMAN RD NE SUITE 100
CONYERS GA
30012-3812
US

V. Phone/Fax

Practice location:
  • Phone: 770-760-9360
  • Fax:
Mailing address:
  • Phone: 770-760-9360
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number1744OOOOOX
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number332BOOOOOX
License Number StateGA

VIII. Authorized Official

Name: DAWNE H TUNKEL
Title or Position: CREDENTIALING DIRECT
Credential: CPC, CMPM, CPMCN
Phone: 865-531-0176