Provider Demographics
NPI:1508444837
Name:INTERVENTIONAL PAIN INSTITUTE LLC
Entity Type:Organization
Organization Name:INTERVENTIONAL PAIN INSTITUTE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:WILLIE
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:FUSSELL
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:229-405-2470
Mailing Address - Street 1:2800 OLD DAWSON RD STE 2, #245
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:GA
Mailing Address - Zip Code:31707-1413
Mailing Address - Country:US
Mailing Address - Phone:229-405-2470
Mailing Address - Fax:229-405-2473
Practice Address - Street 1:3200 GILLIONVILLE RD
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:GA
Practice Address - Zip Code:31721-2815
Practice Address - Country:US
Practice Address - Phone:229-405-2470
Practice Address - Fax:229-405-2473
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-03-30
Last Update Date:2022-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAGA57620OtherGA57620