Healthcare Provider Details

I. General information

NPI: 1679118657
Provider Name (Legal Business Name): PAIN MEDICINE SPECIALISTS, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/13/2019
Last Update Date: 08/05/2020
Certification Date: 08/05/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3410 SUNSET BLVD
WEST COLUMBIA SC
29169-3042
US

IV. Provider business mailing address

1750 HIGHWAY 160 WEST SUITE 101#319
FORT MILL SC
29708-1759
US

V. Phone/Fax

Practice location:
  • Phone: 803-791-9200
  • Fax: 803-791-9207
Mailing address:
  • Phone: 803-802-7100
  • Fax: 803-802-8378

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: MS. COURTNEY SEMKEN
Title or Position: PRACTICE MANAGER
Credential:
Phone: 503-866-1438