Basic Information
| Provider Information | |||||||||
| NPI: | 1063786036 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | THE PAIN CLINIC OF MISSISSIPPI, PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 235019 | ||||||||
| Address2: | |||||||||
| City: | MONTGOMERY | ||||||||
| State: | AL | ||||||||
| PostalCode: | 361235019 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8002325703 | ||||||||
| FaxNumber: | 3343954110 | ||||||||
| Practice Location | |||||||||
| Address1: | 5903 RIDGEWOOD RD | ||||||||
| Address2: | SUITE 440 | ||||||||
| City: | JACKSON | ||||||||
| State: | MS | ||||||||
| PostalCode: | 392113700 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6018993989 | ||||||||
| FaxNumber: | 6018993504 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/08/2012 | ||||||||
| LastUpdateDate: | 03/08/2012 | ||||||||
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| AuthorizedOfficialLastName: | WILLIAMSON | ||||||||
| AuthorizedOfficialFirstName: | DUANE | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 6018993989 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208VP0000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pain Medicine | Pain Medicine | 363LF0000X | Y | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.