Basic Information
| Provider Information | |||||||||
| NPI: | 1316389489 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MEDSTREAM PAIN SERVICES PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 82 PATTON AVE | ||||||||
| Address2: | SUITE 510 | ||||||||
| City: | ASHEVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 288013319 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8282109386 | ||||||||
| FaxNumber: | 8282109388 | ||||||||
| Practice Location | |||||||||
| Address1: | 615 RIDGE RD | ||||||||
| Address2: | |||||||||
| City: | ROXBORO | ||||||||
| State: | NC | ||||||||
| PostalCode: | 275734629 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3365035691 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/18/2013 | ||||||||
| LastUpdateDate: | 07/18/2013 | ||||||||
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| AuthorizedOfficialLastName: | ELLINGTON | ||||||||
| AuthorizedOfficialFirstName: | KENNETH | ||||||||
| AuthorizedOfficialMiddleName: | R | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8282109386 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology | 207LP2900X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology | Pain Medicine |
No ID Information.