Provider Demographics
NPI:1508000332
Name:PRINE, JEREMY JACOB (MD)
Entity Type:Individual
Prefix:
First Name:JEREMY
Middle Name:JACOB
Last Name:PRINE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3200 RIVERSIDE DR
Mailing Address - Street 2:BLDG C
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31210-2550
Mailing Address - Country:US
Mailing Address - Phone:478-474-2947
Mailing Address - Fax:478-971-4004
Practice Address - Street 1:3200 RIVERSIDE DR
Practice Address - Street 2:BLDG C
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31210-2550
Practice Address - Country:US
Practice Address - Phone:478-474-2947
Practice Address - Fax:478-971-4004
Is Sole Proprietor?:No
Enumeration Date:2009-04-23
Last Update Date:2014-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAL071618208VP0014X
GA071618208VP0000X, 207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
No208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain Medicine
No207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA202I728655Medicare PIN