Healthcare Provider Details

I. General information

NPI: 1447185129
Provider Name (Legal Business Name): PAIN TREATMENT CENTERS OF GEORGIA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/15/2026
Last Update Date: 06/15/2026
Certification Date: 06/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

303 HARRIS INDUSTRIAL BLVD
VIDALIA GA
30474-8853
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 TaxonomyY
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number
License Number State

VIII. Authorized Official

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