Healthcare Provider Details

I. General information

NPI: 1609815562
Provider Name (Legal Business Name): PIEDMONT COMPREHENSIVE PAIN MANAGEMENT GROUP LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/06/2006
Last Update Date: 07/30/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 HEALTHY WAY SUITE 1260
ANDERSON SC
29621
US

IV. Provider business mailing address

100 HEALTHY WAY SUITE 1260
ANDERSON SC
29621-2067
US

V. Phone/Fax

Practice location:
  • Phone: 864-225-3551
  • Fax: 864-328-0328
Mailing address:
  • Phone: 864-225-3551
  • Fax: 864-328-0328

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License Number19980
License Number StateSC
# 2
Primary TaxonomyY
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number19467
License Number StateSC
# 3
Primary TaxonomyN
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number20828
License Number StateSC
# 4
Primary TaxonomyN
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number28639
License Number StateSC
# 5
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

Name: GENNA LYNN
Title or Position: OFFICE MANAGER
Credential:
Phone: 864-269-4416