Basic Information
| Provider Information | |||||||||
| NPI: | 1790854206 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | INTERVENTIONAL PAIN INSTITUTE, INCORPORATED | ||||||||
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| Mailing Information | |||||||||
| Address1: | 804 SCOTT NIXON MEMORIAL DR | ||||||||
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| City: | AUGUSTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 309072464 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8003944445 | ||||||||
| FaxNumber: | 7069550735 | ||||||||
| Practice Location | |||||||||
| Address1: | 378 W CHESTNUT ST | ||||||||
| Address2: | SUITE 105 | ||||||||
| City: | WASHINGTON | ||||||||
| State: | PA | ||||||||
| PostalCode: | 153014659 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7242225471 | ||||||||
| FaxNumber: | 7242220305 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/07/2006 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| AuthorizedOfficialLastName: | FUSSELL | ||||||||
| AuthorizedOfficialFirstName: | WILLIE | ||||||||
| AuthorizedOfficialMiddleName: | MICHAEL | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 7242281414 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | DO | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2081P2900X | PA | X | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | Pain Medicine | 208VP0014X | PA | X | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pain Medicine | Interventional Pain Medicine |
No ID Information.