Basic Information
| Provider Information | |||||||||
| NPI: | 1447446570 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PAIN CONSULTANTS OF WEST TENNESSEE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 160 W UNIVERSITY PKWY STE C | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | TN | ||||||||
| PostalCode: | 383051667 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7316605116 | ||||||||
| FaxNumber: | 7316605119 | ||||||||
| Practice Location | |||||||||
| Address1: | 160 W UNIVERSITY PKWY STE C | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | TN | ||||||||
| PostalCode: | 383051667 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7316605116 | ||||||||
| FaxNumber: | 7316605119 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/21/2007 | ||||||||
| LastUpdateDate: | 12/03/2007 | ||||||||
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| AuthorizedOfficialLastName: | JORDAN | ||||||||
| AuthorizedOfficialFirstName: | FRANK | ||||||||
| AuthorizedOfficialMiddleName: | EDWIN | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 7316605116 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207LP2900X | MD14614 | TN | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology | Pain Medicine |
ID Information
| ID | Type | State | Issuer | Description | 3039369 | 01 | TN | BCBS PROVIDER NUMBER | OTHER | 1840642 | 01 | CIGNA PROVIDER NUMBER | OTHER | 3708392 | 05 | TN | MEDICAID |