Provider Demographics
NPI:1336475573
Name:PHYSICIAN'S PAIN AND SPINE CENTER, LLC
Entity Type:Organization
Organization Name:PHYSICIAN'S PAIN AND SPINE CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:RUSSELL
Authorized Official - Last Name:GROSSLIGHT
Authorized Official - Suffix:
Authorized Official - Credentials:MD, JD
Authorized Official - Phone:803-724-2336
Mailing Address - Street 1:3227-F SUNSET BLVD.
Mailing Address - Street 2:SUITE 102
Mailing Address - City:WEST COUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29169-3201
Mailing Address - Country:US
Mailing Address - Phone:803-724-2336
Mailing Address - Fax:803-724-2317
Practice Address - Street 1:3227-F SUNSET BLVD.
Practice Address - Street 2:SUITE 102
Practice Address - City:WEST COUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29169-3201
Practice Address - Country:US
Practice Address - Phone:803-724-2336
Practice Address - Fax:803-724-2317
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-10-22
Last Update Date:2015-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207LP2900X
SC208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain MedicineGroup - Single Specialty
No207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP5286Medicaid
SCGP5286Medicaid