Provider Demographics
NPI:1518012004
Name:INTERVENTIONAL SPINE AND PAIN MANAGEMENT CENTER, PC
Entity Type:Organization
Organization Name:INTERVENTIONAL SPINE AND PAIN MANAGEMENT CENTER, PC
Other - Org Name:ALLIANCE SPINE AND PAIN CENTERS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBIN
Authorized Official - Middle Name:J
Authorized Official - Last Name:FOWLER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:770-929-9033
Mailing Address - Street 1:3390 PEACHTREE RD NE
Mailing Address - Street 2:SUITE 1500
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30326-1157
Mailing Address - Country:US
Mailing Address - Phone:770-929-9033
Mailing Address - Fax:
Practice Address - Street 1:1388 WELLBROOK CIR NE
Practice Address - Street 2:
Practice Address - City:CONYERS
Practice Address - State:GA
Practice Address - Zip Code:30012-3872
Practice Address - Country:US
Practice Address - Phone:404-920-4950
Practice Address - Fax:404-920-4959
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-24
Last Update Date:2021-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAGRP7921Medicare PIN