Basic Information
| Provider Information | |||||||||
| NPI: | 1073855573 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SOUTHERN PAIN INSTITUTE PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 739 PRESIDENT PL | ||||||||
| Address2: | SUITE 220 | ||||||||
| City: | SMYRNA | ||||||||
| State: | TN | ||||||||
| PostalCode: | 371676844 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6154593244 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1608 WILLIAMS DR STE 300 | ||||||||
| Address2: | |||||||||
| City: | MURFREESBORO | ||||||||
| State: | TN | ||||||||
| PostalCode: | 371293195 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6154593244 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/22/2013 | ||||||||
| LastUpdateDate: | 10/30/2018 | ||||||||
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| AuthorizedOfficialLastName: | MOLETTE | ||||||||
| AuthorizedOfficialFirstName: | ANNA-LOUISE | ||||||||
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| AuthorizedOfficialTitleorPosition: | PHYSICIAN | ||||||||
| AuthorizedOfficialTelephone: | 6154593244 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2081P2900X | TN34231 | TN | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | Pain Medicine |
ID Information
| ID | Type | State | Issuer | Description | 3736847 | 05 | TN | MEDICAID |