MEDICARE: SOUTHERN PAIN CENTER, 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	207LP2900X	Pain Medicine (Anesthesiology) Physician		LA
2	208VP0014X	Interventional Pain Medicine Physician		LA

General Provider Information

NPI Number	:	1093982068
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUTHERN PAIN CENTER, LLC

Provider Business Mailing Address
First Line	:	235 SAINT ANN DR
Second Line	:	STE 2
City	:	MANDEVILLE
State	:	LA
Zip	:	70471-3396
Country	:	US
Telephone Number	:	985-727-7275
Fax Number	:	985-727-7915

Provider Business Practice Location Address
First Line	:	235 SAINT ANN DR
Second Line	:	STE 2
City	:	MANDEVILLE
State	:	LA
Zip	:	70471-3396
Country	:	US
Telephone Number	:	985-727-7275
Fax Number	:	985-727-7915

Authorized Official
Title or Position	:	OWNER
Name	:	DR. MARK S DENNIS
Credential	:	MD
Telephone Number	:	985-727-7275

Provider Enumeration Date	:	05/09/2008
Last Update Date	:	09/30/2008

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