Basic Information
Provider Information | |||||||||
NPI: | 1295886497 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | EASTERN REGIONAL PAIN SPECIALISTS, P.A. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1208 PARKWAY DR STE C | ||||||||
Address2: |   | ||||||||
City: | GOLDSBORO | ||||||||
State: | NC | ||||||||
PostalCode: | 275349432 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9197518444 | ||||||||
FaxNumber: | 9197510890 | ||||||||
Practice Location | |||||||||
Address1: | 2605 HOSPITAL RD | ||||||||
Address2: |   | ||||||||
City: | GOLDSBORO | ||||||||
State: | NC | ||||||||
PostalCode: | 275349424 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9197518444 | ||||||||
FaxNumber: | 9197510890 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/15/2007 | ||||||||
LastUpdateDate: | 07/22/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | LONG | ||||||||
AuthorizedOfficialFirstName: | RONALD | ||||||||
AuthorizedOfficialMiddleName: | MORGAN | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 9197518444 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | DR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | M.D. | ||||||||
NPICertificationDate: | 07/22/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X | 138987 | NC | N |   | Suppliers | Durable Medical Equipment & Medical Supplies |   | 208VP0014X | 138987 | NC | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pain Medicine | Interventional Pain Medicine |
ID Information
ID | Type | State | Issuer | Description | DG8738 | 01 | NC | RAILROAD MEDICARE | OTHER |