Basic Information
| Provider Information | |||||||||
| NPI: | 1275045783 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GEORGIA PAIN AND WELLNESS CENTER, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | SUMMIT SPINE & JOINT CENTERS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 455 PHILIP BLVD STE 140 | ||||||||
| Address2: | |||||||||
| City: | LAWRENCEVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300468768 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7709623642 | ||||||||
| FaxNumber: | 7709623643 | ||||||||
| Practice Location | |||||||||
| Address1: | 1200 BALD RIDGE MARINA RD STE 150 | ||||||||
| Address2: | |||||||||
| City: | CUMMING | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300418526 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7709623642 | ||||||||
| FaxNumber: | 7709623643 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/25/2017 | ||||||||
| LastUpdateDate: | 03/31/2021 | ||||||||
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| AuthorizedOfficialLastName: | PATEL | ||||||||
| AuthorizedOfficialFirstName: | AMIT | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 7709623642 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | GEORGIA PAIN AND WELLNESS CENTER, LLC | ||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 03/31/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207LP2900X | N | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology | Pain Medicine | 208VP0014X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pain Medicine | Interventional Pain Medicine |
No ID Information.