=====================================================
General NPI Number Information
=====================================================
NPI Number | 1174697106
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SOUTHERN PAIN SPECIALISTS, P.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/20/2006
-----------------------------------------------------
Last Update Date | 06/12/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7191 CAHABA VALLEY RD SUITE 204
-----------------------------------------------------
City | BIRMINGHAM
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 35242-6402
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 205-995-9967
-----------------------------------------------------
Fax | 205-995-0635
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7191 CAHABA VALLEY RD SUITE 204
-----------------------------------------------------
City | BIRMINGHAM
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 35242-6402
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 205-995-9967
-----------------------------------------------------
Fax | 205-995-0635
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. KENNETH G VARLEY
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 205-995-9967
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | 491
-----------------------------------------------------
License Number State | AL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 208VP0014X
-----------------------------------------------------
Taxonomy Name | Interventional Pain Medicine Physician
-----------------------------------------------------
License Number | 19582
-----------------------------------------------------
License Number State | AL
-----------------------------------------------------