MEDICARE: SOUTHERN PAIN AND SPINE ASSOCIATES LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208VP0014X	Interventional Pain Medicine Physician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	72139	OTHER	GA	GCMB

General Provider Information

NPI Number	:	1093469355
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUTHERN PAIN AND SPINE ASSOCIATES LLC

Provider Business Mailing Address
First Line	:	PO BOX 28415
Second Line	:
City	:	BELFAST
State	:	ME
Zip	:	04915-2036
Country	:	US
Telephone Number	:	888-488-8289
Fax Number	:	502-919-9780

Provider Business Practice Location Address
First Line	:	1101 OLD PHILADELPHIA RD STE G100
Second Line	:
City	:	JASPER
State	:	GA
Zip	:	30143-4044
Country	:	US
Telephone Number	:	678-971-4167
Fax Number	:	833-989-2501

Authorized Official
Title or Position	:	COO
Name	:	HAMISH PATEL
Credential	:
Telephone Number	:	470-628-9203

Provider Enumeration Date	:	02/07/2022
Last Update Date	:	05/25/2022

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