Healthcare Provider Details

I. General information

NPI: 1033509203
Provider Name (Legal Business Name): PAIN ASSOCIATES OF SOUTH GEORGIA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/27/2015
Last Update Date: 01/28/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

306 ISABELLA ST
WAYCROSS GA
31501-3636
US

IV. Provider business mailing address

306 ISABELLA ST
WAYCROSS GA
31501-3636
US

V. Phone/Fax

Practice location:
  • Phone: 912-267-9000
  • Fax: 912-267-9028
Mailing address:
  • Phone: 912-490-7246
  • Fax: 912-490-7247

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number038152
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

Name: DR. MICHAEL J LUPI
Title or Position: MEDICAL DIRECTOR
Credential: DO
Phone: 912-267-9000