Healthcare Provider Details

I. General information

NPI: 1619702792
Provider Name (Legal Business Name): PAIN TREATMENT CENTERS OF GEORGIA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/06/2024
Last Update Date: 09/06/2024
Certification Date: 09/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6606 ABERCORN ST
SAVANNAH GA
31405-5817
US

IV. Provider business mailing address

604 W OGLETHORPE HWY
HINESVILLE GA
31313-4415
US

V. Phone/Fax

Practice location:
  • Phone: 912-910-3777
  • Fax: 912-292-0005
Mailing address:
  • Phone: 912-910-3777
  • Fax: 912-292-0005

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QP3300X
TaxonomyPain Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State

VIII. Authorized Official

Name: VADIM PETROV-KONDRATOV
Title or Position: OWNER
Credential: MD
Phone: 912-910-3777