Healthcare Provider Details

I. General information

NPI: 1912253725
Provider Name (Legal Business Name): INTERVENTIONAL PAIN MANAGEMENT ASSOCIATES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/30/2012
Last Update Date: 12/07/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21 BRENDAN WAY
GREENVILLE SC
29615-3514
US

IV. Provider business mailing address

PO BOX 2545
COLUMBUS GA
31902-2545
US

V. Phone/Fax

Practice location:
  • Phone: 864-385-7070
  • Fax: 864-385-7071
Mailing address:
  • Phone: 706-660-8505
  • Fax: 706-660-9390

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. KEVIN B WALKER
Title or Position: PRESIDENT
Credential: M.D.
Phone: 706-660-8505