Provider Demographics
NPI:1407892417
Name:DEKALB PAIN CENTER
Entity Type:Organization
Organization Name:DEKALB PAIN CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CODING/BILLING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:PAM
Authorized Official - Middle Name:
Authorized Official - Last Name:DIDONATO
Authorized Official - Suffix:
Authorized Official - Credentials:CPC
Authorized Official - Phone:678-514-2643
Mailing Address - Street 1:2171 W PARK CT
Mailing Address - Street 2:SUITE B
Mailing Address - City:STONE MOUNTAIN
Mailing Address - State:GA
Mailing Address - Zip Code:30087-3555
Mailing Address - Country:US
Mailing Address - Phone:678-514-1991
Mailing Address - Fax:678-514-1993
Practice Address - Street 1:2675 N DECATUR RD
Practice Address - Street 2:SUITE 110
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30033-6131
Practice Address - Country:US
Practice Address - Phone:404-501-5368
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-20
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA208VP0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA=========OtherTAX ID
GAGRP2246Medicare PIN