MEDICARE: CUMBERLAND BACK PAIN CLINIC

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	363A00000X	Physician Assistant	PA918	TN

General Provider Information

NPI Number	:	1932310828
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CUMBERLAND BACK PAIN CLINIC

Provider Business Mailing Address
First Line	:	1732 N EASTMAN RD
Second Line	:
City	:	KINGSPORT
State	:	TN
Zip	:	37664-2376
Country	:	US
Telephone Number	:	615-591-2754
Fax Number	:	615-591-2755

Provider Business Practice Location Address
First Line	:	1732 N EASTMAN RD
Second Line	:
City	:	KINGSPORT
State	:	TN
Zip	:	37664-2376
Country	:	US
Telephone Number	:	615-591-2754
Fax Number	:	615-591-2755

Authorized Official
Title or Position	:	BILLING MANAGER
Name	:	ANNETTE M DREIFKE
Credential	:
Telephone Number	:	615-591-2754

Provider Enumeration Date	:	05/24/2007
Last Update Date	:	08/22/2020

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