Healthcare Provider Details

I. General information

NPI: 1982669339
Provider Name (Legal Business Name): ADVANCED INTERVENTIONAL PAIN MANAGEMENT, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/19/2006
Last Update Date: 01/06/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

160 KIMEL FOREST DR SUITE100
WINSTON SALEM NC
27103-6074
US

IV. Provider business mailing address

160 KIMEL FOREST DR SUITE 100
WINSTON SALEM NC
27103-6074
US

V. Phone/Fax

Practice location:
  • Phone: 336-714-6400
  • Fax: 336-714-6402
Mailing address:
  • Phone: 336-714-6400
  • Fax: 336-714-6402

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: MRS. JOHNETTE CAROL SHULTZ
Title or Position: CFO, PRACTICE ADMINISTRATOR
Credential:
Phone: 336-714-6406