Healthcare Provider Details

I. General information

NPI: 1215198643
Provider Name (Legal Business Name): PAIN CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/18/2008
Last Update Date: 06/18/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

294 CHUBBY DR SUITE 2
COLUMBUS MS
39705-1358
US

IV. Provider business mailing address

765 TASSO LN NE
CLEVELAND TN
37312-4559
US

V. Phone/Fax

Practice location:
  • Phone: 662-327-6820
  • Fax:
Mailing address:
  • Phone: 423-903-6796
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number11125
License Number StateMS

VIII. Authorized Official

Name: DR. MICHAEL A WHITE
Title or Position: PRESIDENT
Credential: MD
Phone: 423-903-6796