Basic Information
| Provider Information | |||||||||
| NPI: | 1134544570 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SC PAIN & SPINE SPECIALISTS, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 4057 | ||||||||
| Address2: | |||||||||
| City: | PAWLEYS ISLAND | ||||||||
| State: | SC | ||||||||
| PostalCode: | 295854057 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8438397246 | ||||||||
| FaxNumber: | 8438397323 | ||||||||
| Practice Location | |||||||||
| Address1: | 812 FARRAR DR | ||||||||
| Address2: | SUITE - B | ||||||||
| City: | CONWAY | ||||||||
| State: | SC | ||||||||
| PostalCode: | 295268747 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8438397246 | ||||||||
| FaxNumber: | 8438397323 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/21/2014 | ||||||||
| LastUpdateDate: | 01/20/2015 | ||||||||
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| AuthorizedOfficialLastName: | ROSENBERG | ||||||||
| AuthorizedOfficialFirstName: | JASON | ||||||||
| AuthorizedOfficialMiddleName: | CHARLES | ||||||||
| AuthorizedOfficialTitleorPosition: | MEMBER | ||||||||
| AuthorizedOfficialTelephone: | 8438397246 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P2900X | 24751 | SC | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Pain Medicine | 208VP0014X | 24751 | SC | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pain Medicine | Interventional Pain Medicine |
ID Information
| ID | Type | State | Issuer | Description | GP5802 | 05 | SC | MEDICAID |