Provider Demographics
NPI:1326053760
Name:SOUTHEASTERN PAIN MANAGEMENT CENTER, PLLC
Entity Type:Organization
Organization Name:SOUTHEASTERN PAIN MANAGEMENT CENTER, PLLC
Other - Org Name:SOUTHEASTERN PAIN MANAGEMENT CENTER
Other - Org Type:Other Name
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:DENNIS
Authorized Official - Middle Name:M
Authorized Official - Last Name:AGUIRRE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:423-968-4540
Mailing Address - Street 1:350 BLOUNTVILLE HWY
Mailing Address - Street 2:STE 207
Mailing Address - City:BRISTOL
Mailing Address - State:TN
Mailing Address - Zip Code:37620-0213
Mailing Address - Country:US
Mailing Address - Phone:423-968-4540
Mailing Address - Fax:423-968-5697
Practice Address - Street 1:3183 W STATE ST
Practice Address - Street 2:SUITE 1101
Practice Address - City:BRISTOL
Practice Address - State:TN
Practice Address - Zip Code:37620-1712
Practice Address - Country:US
Practice Address - Phone:423-968-2772
Practice Address - Fax:423-968-1377
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-31
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3717376Medicare ID - Type UnspecifiedMEDICARE