Provider Demographics
NPI:1295377497
Name:SOUTHERN PAIN AND REHABILITATION INC
Entity Type:Organization
Organization Name:SOUTHERN PAIN AND REHABILITATION INC
Other - Org Name:ELITE PAIN AND SPINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:T
Authorized Official - Last Name:RUXER
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:812-639-9453
Mailing Address - Street 1:4645 VILLAGE SQUARE DR STE C
Mailing Address - Street 2:
Mailing Address - City:PADUCAH
Mailing Address - State:KY
Mailing Address - Zip Code:42001-7448
Mailing Address - Country:US
Mailing Address - Phone:270-228-0118
Mailing Address - Fax:
Practice Address - Street 1:4645 VILLAGE SQUARE DR STE C
Practice Address - Street 2:
Practice Address - City:PADUCAH
Practice Address - State:KY
Practice Address - Zip Code:42001-7448
Practice Address - Country:US
Practice Address - Phone:270-228-0118
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-10-09
Last Update Date:2021-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain MedicineGroup - Multi-Specialty
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontologyGroup - Multi-Specialty