Provider Demographics
NPI:1508959230
Name:PIEDMONT INTERVENTIONAL SPINE AND PAIN CENTER, LLC
Entity Type:Organization
Organization Name:PIEDMONT INTERVENTIONAL SPINE AND PAIN CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SANJAY
Authorized Official - Middle Name:
Authorized Official - Last Name:NANDURKAR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:803-289-7246
Mailing Address - Street 1:901 W MEETING ST STE 200
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:SC
Mailing Address - Zip Code:29720-6200
Mailing Address - Country:US
Mailing Address - Phone:803-289-7246
Mailing Address - Fax:803-285-1522
Practice Address - Street 1:901 W MEETING ST STE 200
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:SC
Practice Address - Zip Code:29720-6200
Practice Address - Country:US
Practice Address - Phone:803-289-7246
Practice Address - Fax:803-285-1522
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-02
Last Update Date:2023-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC293275Medicaid
SC293275Medicaid