Basic Information
| Provider Information | |||||||||
| NPI: | 1245654615 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GEORGIA INTERVENTIONAL PAIN LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 455 PHILIP BLVD STE 140 | ||||||||
| Address2: | |||||||||
| City: | LAWRENCEVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300468768 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7709623642 | ||||||||
| FaxNumber: | 7709623642 | ||||||||
| Practice Location | |||||||||
| Address1: | 455 PHILIP BLVD STE 138 | ||||||||
| Address2: | |||||||||
| City: | LAWRENCEVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300468767 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7709623642 | ||||||||
| FaxNumber: | 7709623642 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/05/2014 | ||||||||
| LastUpdateDate: | 03/30/2021 | ||||||||
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| AuthorizedOfficialLastName: | PATEL | ||||||||
| AuthorizedOfficialFirstName: | AMIT | ||||||||
| AuthorizedOfficialMiddleName: | SURYAKANT | ||||||||
| AuthorizedOfficialTitleorPosition: | MEDICAL DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 7576185889 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | 03/30/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QA1903X | 62929 | GA | Y | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Surgical |
No ID Information.