Healthcare Provider Details

I. General information

NPI: 1639483100
Provider Name (Legal Business Name): HANOWELL PAIN MANAGEMENT LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/27/2010
Last Update Date: 02/08/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5126 HOSPITAL DR NE
COVINGTON GA
30014-2566
US

IV. Provider business mailing address

PO BOX 7096
STOCKTON CA
95267-0096
US

V. Phone/Fax

Practice location:
  • Phone: 770-385-4426
  • Fax:
Mailing address:
  • Phone: 209-956-7725
  • Fax: 209-956-7733

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License Number061846
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number061846
License Number StateGA

VIII. Authorized Official

Name: MICHAEL HANOWELL
Title or Position: OWNER
Credential: MD
Phone: 770-385-4426