Provider Demographics
NPI:1215201355
Name:AUGUSTA INTERVENTIONAL PAIN AND REHABILITATION
Entity Type:Organization
Organization Name:AUGUSTA INTERVENTIONAL PAIN AND REHABILITATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:VENKATA
Authorized Official - Middle Name:
Authorized Official - Last Name:LAKKIMSETTY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:419-508-4608
Mailing Address - Street 1:720 BON AIR DR
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30907-4872
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1355 INDEPENDENCE DR
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30901-1037
Practice Address - Country:US
Practice Address - Phone:419-508-4608
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-07
Last Update Date:2012-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA67138208100000X, 2081P2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty
No2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain MedicineGroup - Multi-Specialty