MEDICARE: INTERVENTIONAL PAIN CENTER, PLLC

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	2081P2900X	Pain Medicine (Physical Medicine & Rehabilitation) Physician	DO0000002339	TN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1285976407
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	INTERVENTIONAL PAIN CENTER, PLLC

Provider Business Mailing Address
First Line	:	353 NEW SHACKLE ISLAND RD
Second Line	:	SUITE 101-A
City	:	HENDERSONVILLE
State	:	TN
Zip	:	37075-2379
Country	:	US
Telephone Number	:	615-972-1100
Fax Number	:	615-537-4950

Provider Business Practice Location Address
First Line	:	353 NEW SHACKLE ISLAND RD STE 148C
Second Line	:
City	:	HENDERSONVILLE
State	:	TN
Zip	:	37075-2366
Country	:	US
Telephone Number	:	615-972-1000
Fax Number	:	615-537-4950

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. BRAD PAUL WILSON
Credential	:	DO
Telephone Number	:	615-972-1100

Provider Enumeration Date	:	03/26/2013
Last Update Date	:	10/17/2023

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