Provider Demographics
NPI:1508922865
Name:INSTITUTE FOR SPINAL PAIN TREATMENT
Entity Type:Organization
Organization Name:INSTITUTE FOR SPINAL PAIN TREATMENT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:L
Authorized Official - Last Name:MCKELLAR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:601-264-2115
Mailing Address - Street 1:1 LINCOLN PARKWAY
Mailing Address - Street 2:SUITE 106
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39402
Mailing Address - Country:US
Mailing Address - Phone:601-264-2115
Mailing Address - Fax:601-264-1519
Practice Address - Street 1:1 LINCOLN PARKWAY
Practice Address - Street 2:SUITE 106
Practice Address - City:HATTIESBURG
Practice Address - State:MS
Practice Address - Zip Code:39402
Practice Address - Country:US
Practice Address - Phone:601-264-2115
Practice Address - Fax:601-264-1519
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-29
Last Update Date:2011-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP3300XAmbulatory Health Care FacilitiesClinic/CenterPain
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS07439015Medicaid
MS490000062Medicare ID - Type Unspecified
MS490000026Medicare PIN