Basic Information
| Provider Information | |||||||||
| NPI: | 1326053760 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SOUTHEASTERN PAIN MANAGEMENT CENTER, PLLC | ||||||||
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| OtherOrganizationName: | SOUTHEASTERN PAIN MANAGEMENT CENTER | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 350 BLOUNTVILLE HWY | ||||||||
| Address2: | STE 207 | ||||||||
| City: | BRISTOL | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376200213 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4239684540 | ||||||||
| FaxNumber: | 4239685697 | ||||||||
| Practice Location | |||||||||
| Address1: | 3183 W STATE ST | ||||||||
| Address2: | SUITE 1101 | ||||||||
| City: | BRISTOL | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376201712 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4239682772 | ||||||||
| FaxNumber: | 4239681377 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/31/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | AGUIRRE | ||||||||
| AuthorizedOfficialFirstName: | DENNIS | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | MEDICAL DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 4239684540 | ||||||||
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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 | 207LP2900X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology | Pain Medicine |
No ID Information.