Basic Information
| Provider Information | |||||||||
| NPI: | 1902424914 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GEORGIA PAIN AND WELLNESS CENTER, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | SUMMIT SINE & JOINT CENTERS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 455 PHILIP BLVD STE 140 | ||||||||
| Address2: | |||||||||
| City: | LAWRENCEVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300468768 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7709623642 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1504 N THORNTON AVE STE 103 | ||||||||
| Address2: | |||||||||
| City: | DALTON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 307208394 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7709623642 | ||||||||
| FaxNumber: | 7709623643 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/07/2020 | ||||||||
| LastUpdateDate: | 03/31/2021 | ||||||||
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| AuthorizedOfficialLastName: | PATEL | ||||||||
| AuthorizedOfficialFirstName: | AMIT | ||||||||
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| AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 4049529066 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | GEORGIA PAIN AND WELLNESS CENTER, LLC | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 03/31/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208VP0000X | N | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pain Medicine | Pain Medicine | 208VP0014X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pain Medicine | Interventional Pain Medicine |
No ID Information.