Provider Demographics
NPI:1558428789
Name:INTERVENTIONAL PAIN CENTER PLLC
Entity Type:Organization
Organization Name:INTERVENTIONAL PAIN CENTER PLLC
Other - Org Name:FAYETTEVILLE PAIN CENTER, PLLC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PHYSICIAN OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:VIREN
Authorized Official - Middle Name:D
Authorized Official - Last Name:DESAI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:910-321-7246
Mailing Address - Street 1:2153 VALLEYGATE DR
Mailing Address - Street 2:SUITE 102
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28304-3681
Mailing Address - Country:US
Mailing Address - Phone:910-321-7246
Mailing Address - Fax:910-321-7245
Practice Address - Street 1:2153 VALLEYGATE DR
Practice Address - Street 2:SUITE 102
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28304-3681
Practice Address - Country:US
Practice Address - Phone:910-321-7246
Practice Address - Fax:910-321-7245
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-03
Last Update Date:2017-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC200100673207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC89014Y4Medicaid
NC6086600001Medicare NSC
NC89014Y4Medicaid
2334998Medicare PIN