Basic Information
Provider Information | |||||||||
NPI: | 1215596135 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | PAIN MANAGEMENT PLUS PLLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 1641 | ||||||||
Address2: |   | ||||||||
City: | BRYSON CITY | ||||||||
State: | NC | ||||||||
PostalCode: | 287131641 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9802795801 | ||||||||
FaxNumber: | 8285384441 | ||||||||
Practice Location | |||||||||
Address1: | 249 OAK ST | ||||||||
Address2: |   | ||||||||
City: | FOREST CITY | ||||||||
State: | NC | ||||||||
PostalCode: | 280433585 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9802795801 | ||||||||
FaxNumber: | 8289192394 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/13/2019 | ||||||||
LastUpdateDate: | 06/22/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | HEWITT | ||||||||
AuthorizedOfficialFirstName: | DONNA | ||||||||
AuthorizedOfficialMiddleName: | LYNN | ||||||||
AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
AuthorizedOfficialTelephone: | 8289192393 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | NP | ||||||||
NPICertificationDate: | 06/22/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 6815645 | 01 | NC | UHC | OTHER | 1215596135 | 05 | NC |   | MEDICAID | QY95 | 01 | NC | BLUE MEDICARE | OTHER | 02FLR | 01 | NC | BCBS NC | OTHER | NPC102 | 05 | SC |   | MEDICAID | 10125636 | 01 | NC | MULTIPLAN | OTHER | DZ3967 | 01 | NC | RAILROAD MEDICARE | OTHER | J277 | 01 | NC | MEDICARE | OTHER |