Provider Demographics
NPI:1407315948
Name:SOUTHERN INTERVENTIONAL PAIN CENTER LLC
Entity Type:Organization
Organization Name:SOUTHERN INTERVENTIONAL PAIN CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:MAXIMILIAN
Authorized Official - Middle Name:SHAHRYAR
Authorized Official - Last Name:SHOKAT
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:229-226-2234
Mailing Address - Street 1:615 S HANSELL ST
Mailing Address - Street 2:
Mailing Address - City:THOMASVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31792-5556
Mailing Address - Country:US
Mailing Address - Phone:229-226-2234
Mailing Address - Fax:229-226-2237
Practice Address - Street 1:1931 WELBY WAY STE 4
Practice Address - Street 2:
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32308-4473
Practice Address - Country:US
Practice Address - Phone:850-404-9400
Practice Address - Fax:855-313-1262
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SOUTHERN INTERVENTIONAL PAIN CENTER LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-03-14
Last Update Date:2020-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain MedicineGroup - Single Specialty
No2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Multi-Specialty