=====================================================
General NPI Number Information
=====================================================
NPI Number | 1588836332
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PAIN MANAGEMENT CONSULTANTS PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/01/2008
-----------------------------------------------------
Last Update Date | 04/01/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 971 LAKELAND DR SUITE 1060
-----------------------------------------------------
City | JACKSON
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39216-4643
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 601-540-8059
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 3251
-----------------------------------------------------
City | RIDGELAND
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39158-3251
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | REX B WILLIAMS
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 601-540-8059
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208VP0000X
-----------------------------------------------------
Taxonomy Name | Pain Medicine Physician
-----------------------------------------------------
License Number | 19128
-----------------------------------------------------
License Number State | MS
-----------------------------------------------------