Basic Information
| Provider Information | |||||||||
| NPI: | 1538557780 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SC PAIN AND SPINE SPECIALIST | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4731 HWY 17 BYPASS S | ||||||||
| Address2: | |||||||||
| City: | MURRELLS INLET | ||||||||
| State: | SC | ||||||||
| PostalCode: | 29576 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8438397246 | ||||||||
| FaxNumber: | 8438397323 | ||||||||
| Practice Location | |||||||||
| Address1: | 230 S FRASER STREET | ||||||||
| Address2: | |||||||||
| City: | GEORGETOWN | ||||||||
| State: | SC | ||||||||
| PostalCode: | 29440 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8434614735 | ||||||||
| FaxNumber: | 8438397323 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/22/2014 | ||||||||
| LastUpdateDate: | 01/20/2015 | ||||||||
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| AuthorizedOfficialLastName: | ROSENBERG | ||||||||
| AuthorizedOfficialFirstName: | JASON | ||||||||
| AuthorizedOfficialMiddleName: | C | ||||||||
| AuthorizedOfficialTitleorPosition: | MEMBER | ||||||||
| AuthorizedOfficialTelephone: | 8438397246 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | SC PAIN AND SPINE SPECIALIST, LLC | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208VP0014X | 24751 | SC | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pain Medicine | Interventional Pain Medicine |
No ID Information.