Healthcare Provider Details

I. General information

NPI: 1255396933
Provider Name (Legal Business Name): SOUTHEAST PAIN MANAGEMENT SERVICES, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/18/2006
Last Update Date: 10/18/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

927 EAST BLVD
CHARLOTTE NC
28203-5203
US

IV. Provider business mailing address

927 EAST BLVD
CHARLOTTE NC
28203-5203
US

V. Phone/Fax

Practice location:
  • Phone: 704-377-5772
  • Fax: 707-377-3389
Mailing address:
  • Phone: 704-377-5772
  • Fax: 707-377-3389

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: MR. WILLIAM HAWK
Title or Position: VICE PRESIDENT
Credential:
Phone: 954-384-0175