Healthcare Provider Details

I. General information

NPI: 1609196971
Provider Name (Legal Business Name): GWINNETT INTERVENTIONAL PAIN, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/09/2010
Last Update Date: 06/09/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1090 RIVER LAUREL DR
SUWANEE GA
30024-6932
US

IV. Provider business mailing address

1090 RIVER LAUREL DR
SUWANEE GA
30024-6932
US

V. Phone/Fax

Practice location:
  • Phone: 770-979-9996
  • Fax: 770-979-1202
Mailing address:
  • Phone: 770-979-9996
  • Fax: 770-979-1202

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: JUDY CHESIN
Title or Position: ADMINISTRATOR
Credential:
Phone: 770-979-9996