Provider Demographics
NPI:1245212935
Name:PAIN SOUTH PA
Entity Type:Organization
Organization Name:PAIN SOUTH PA
Other - Org Name:PAIN SOUTH PA DBA HOT SPRINGS INTERVENTIONAL PAIN MANAGEMENT
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICER
Authorized Official - Prefix:DR
Authorized Official - First Name:JACOB
Authorized Official - Middle Name:E
Authorized Official - Last Name:ABRAHAM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:501-321-4772
Mailing Address - Street 1:1 MERCY LN
Mailing Address - Street 2:SUITE 304
Mailing Address - City:HOT SPRINGS
Mailing Address - State:AR
Mailing Address - Zip Code:71913-6442
Mailing Address - Country:US
Mailing Address - Phone:501-321-4772
Mailing Address - Fax:501-321-3543
Practice Address - Street 1:1 MERCY LN
Practice Address - Street 2:SUITE 304
Practice Address - City:HOT SPRINGS
Practice Address - State:AR
Practice Address - Zip Code:71913-6442
Practice Address - Country:US
Practice Address - Phone:501-321-4772
Practice Address - Fax:501-321-3543
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-17
Last Update Date:2008-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP3300XAmbulatory Health Care FacilitiesClinic/CenterPain
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR121454001Medicaid
AR125247001Medicaid
AR121454001Medicaid
ARF80667Medicare UPIN
AR125247001Medicaid
ARE51678Medicare UPIN
AR5B556Medicare PIN