Provider Demographics
NPI:1083631824
Name:PAIN AND ORTHOPEDIC NEUROLOGY, PA
Entity Type:Organization
Organization Name:PAIN AND ORTHOPEDIC NEUROLOGY, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ANTHONY
Authorized Official - Middle Name:HALLOCK
Authorized Official - Last Name:WHEELER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:704-365-0966
Mailing Address - Street 1:3711 LATROBE DR STE 530
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28211-1664
Mailing Address - Country:US
Mailing Address - Phone:704-365-0966
Mailing Address - Fax:704-362-3691
Practice Address - Street 1:3711 LATROBE DR STE 530
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28211-1664
Practice Address - Country:US
Practice Address - Phone:704-365-0966
Practice Address - Fax:704-362-3691
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-17
Last Update Date:2010-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC288192084P2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P2900XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPain MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC211452FMedicare PIN
NCC87108Medicare UPIN