Basic Information
| Provider Information | |||||||||
| NPI: | 1811928724 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PAIN MANAGEMENT CENTER OF NORTH | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | PAIN MANAGEMENT CENTER OF N MS PLLC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 11407 | ||||||||
| Address2: | |||||||||
| City: | BIRMINGHAM | ||||||||
| State: | AL | ||||||||
| PostalCode: | 352461218 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8008976169 | ||||||||
| FaxNumber: | 8008976170 | ||||||||
| Practice Location | |||||||||
| Address1: | 2089 SOUTHRIDGE DR | ||||||||
| Address2: | |||||||||
| City: | TUPELO | ||||||||
| State: | MS | ||||||||
| PostalCode: | 388016478 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6624070801 | ||||||||
| FaxNumber: | 6624070807 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/06/2006 | ||||||||
| LastUpdateDate: | 01/06/2010 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | HAMMITT | ||||||||
| AuthorizedOfficialFirstName: | GEORGE | ||||||||
| AuthorizedOfficialMiddleName: | MONROE | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 6624070801 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | III | ||||||||
| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP3300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Pain |
ID Information
| ID | Type | State | Issuer | Description | DC4899 | 01 | MS | RAILROAD MEDICARE | OTHER | 07277812 | 05 | MS | MEDICAID |