Healthcare Provider Details

I. General information

NPI: 1003094442
Provider Name (Legal Business Name): HEAG PAIN MANAGEMENT CENTER PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/07/2008
Last Update Date: 09/05/2023
Certification Date: 09/05/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2609 N DUKE ST STE 303B
DURHAM NC
27704
US

IV. Provider business mailing address

2609 N DYKE ST SUITE 402
DURHAM NC
27704
US

V. Phone/Fax

Practice location:
  • Phone: 919-220-0107
  • Fax:
Mailing address:
  • Phone: 919-220-0107
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number200500050
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License Number200500050
License Number StateNC
# 3
Primary TaxonomyN
Taxonomy Code261QP3300X
TaxonomyPain Clinic/Center
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number200500050
License Number StateNC

VIII. Authorized Official

Name: DR. KWADWO GYARTENG DAKWA
Title or Position: PHYSICAN
Credential: MD
Phone: 919-220-0107