Healthcare Provider Details

I. General information

NPI: 1245654615
Provider Name (Legal Business Name): GEORGIA INTERVENTIONAL PAIN LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/05/2014
Last Update Date: 01/13/2023
Certification Date: 01/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

455 PHILIP BLVD STE 138
LAWRENCEVILLE GA
30046-8767
US

IV. Provider business mailing address

455 PHILIP BLVD STE 140
LAWRENCEVILLE GA
30046-8768
US

V. Phone/Fax

Practice location:
  • Phone: 770-962-3642
  • Fax: 770-962-3642
Mailing address:
  • Phone: 770-962-3642
  • Fax: 770-962-3642

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number62929
License Number StateGA

VIII. Authorized Official

Name: DR. AMIT SURYAKANT PATEL
Title or Position: MEDICAL DIRECTOR
Credential: M.D.
Phone: 757-618-5889