MEDICARE: PROGRESSIVE PAIN MANAGEMENT, PC

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	171100000X	Acupuncturist	000186	GA
2	207Q00000X	Family Medicine Physician	038861	GA
3	208D00000X	General Practice Physician	038861	GA
4	111N00000X	Chiropractor	006247	GA

General Provider Information

NPI Number	:	1972807865
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PROGRESSIVE PAIN MANAGEMENT, PC

Provider Business Mailing Address
First Line	:	4646 N SHALLOWFORD RD
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30338-6308
Country	:	US
Telephone Number	:	770-676-6000
Fax Number	:

Provider Business Practice Location Address
First Line	:	4646 N SHALLOWFORD RD
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30338-6308
Country	:	US
Telephone Number	:	770-676-6000
Fax Number	:

Authorized Official
Title or Position	:	BILLING/COLLECTION SUPERVISOR
Name	:	MRS. MARY C LEACH
Credential	:
Telephone Number	:	678-736-6342

Provider Enumeration Date	:	01/06/2011
Last Update Date	:	01/06/2011

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