Healthcare Provider Details

I. General information

NPI: 1336474311
Provider Name (Legal Business Name): NORTH GEORGIA PAIN SPECIALIST, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/09/2009
Last Update Date: 10/09/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 GROSS CRESCENT CIR
FT OGLETHORPE GA
30742-3643
US

IV. Provider business mailing address

PO BOX 935012
ATLANTA GA
31193-5012
US

V. Phone/Fax

Practice location:
  • Phone: 706-858-2000
  • Fax:
Mailing address:
  • Phone: 800-555-2049
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. STEVEN GOTTLIEB
Title or Position: PRESIDENT
Credential: MD
Phone: 561-799-3552