Basic Information
Provider Information | |||||||||
NPI: | 1194283267 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | GEORGIA INTERVENTIONAL PAIN - E, LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 455 PHILIP BLVD STE 140 | ||||||||
Address2: |   | ||||||||
City: | LAWRENCEVILLE | ||||||||
State: | GA | ||||||||
PostalCode: | 300468768 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7709623642 | ||||||||
FaxNumber: | 7709623643 | ||||||||
Practice Location | |||||||||
Address1: | 100 LIBERTY BLVD STE 220 | ||||||||
Address2: |   | ||||||||
City: | CANTON | ||||||||
State: | GA | ||||||||
PostalCode: | 301142852 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7709623642 | ||||||||
FaxNumber: | 7709623643 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/07/2019 | ||||||||
LastUpdateDate: | 03/30/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | PATEL | ||||||||
AuthorizedOfficialFirstName: | AMIT | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CEO | ||||||||
AuthorizedOfficialTelephone: | 7709623642 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | DR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | MD | ||||||||
NPICertificationDate: | 03/30/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QA1903X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Surgical |
No ID Information.