Provider Demographics
NPI:1477047199
Name:PAIN & SPINE PHYSICIANS SURGERY CENTER LLC
Entity Type:Organization
Organization Name:PAIN & SPINE PHYSICIANS SURGERY CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:VIRGINIA
Authorized Official - Middle Name:
Authorized Official - Last Name:MINICOZZI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-391-3979
Mailing Address - Street 1:3333 OLD MILTON PKWY STE 430
Mailing Address - Street 2:
Mailing Address - City:ALPHARETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30005-4437
Mailing Address - Country:US
Mailing Address - Phone:770-391-3979
Mailing Address - Fax:770-391-0020
Practice Address - Street 1:3333 OLD MILTON PKWY STE 430
Practice Address - Street 2:
Practice Address - City:ALPHARETTA
Practice Address - State:GA
Practice Address - Zip Code:30005-4437
Practice Address - Country:US
Practice Address - Phone:770-391-3979
Practice Address - Fax:770-391-0020
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-06-16
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical