Provider Demographics
NPI:1437565900
Name:CORDOVA PAIN SPECIALISTS, PLLC
Entity Type:Organization
Organization Name:CORDOVA PAIN SPECIALISTS, PLLC
Other - Org Name:NORTHSTAR PAIN MANAGEMENT
Other - Org Type:Doing Business As
Authorized Official - Title/Position:AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:WYATT
Authorized Official - Last Name:MILES
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:901-444-3950
Mailing Address - Street 1:1540 APPLING CARE LN
Mailing Address - Street 2:SUITE 105
Mailing Address - City:CORDOVA
Mailing Address - State:TN
Mailing Address - Zip Code:38016-4957
Mailing Address - Country:US
Mailing Address - Phone:901-444-3950
Mailing Address - Fax:901-444-3866
Practice Address - Street 1:1540 APPLING CARE LN
Practice Address - Street 2:SUITE 105
Practice Address - City:CORDOVA
Practice Address - State:TN
Practice Address - Zip Code:38016-4957
Practice Address - Country:US
Practice Address - Phone:901-444-3950
Practice Address - Fax:901-444-3866
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-06
Last Update Date:2018-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN2168207L00000X, 208VP0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain MedicineGroup - Multi-Specialty
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1520769Medicaid