Provider Demographics
NPI:1568529303
Name:ATLANTIC PAIN MANAGEMENT & REHABILITATION P.C.
Entity Type:Organization
Organization Name:ATLANTIC PAIN MANAGEMENT & REHABILITATION P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:THEODORE
Authorized Official - Middle Name:W
Authorized Official - Last Name:NICHOLAS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:252-261-5868
Mailing Address - Street 1:3210 N. CROATAN HWY BUILDING 3 SUITE 3
Mailing Address - Street 2:
Mailing Address - City:KILL DEVIL HILLS
Mailing Address - State:NC
Mailing Address - Zip Code:27948
Mailing Address - Country:US
Mailing Address - Phone:252-261-5868
Mailing Address - Fax:252-441-7793
Practice Address - Street 1:3210 N. CROATAN HWY BUILDING 3 SUITE 3
Practice Address - Street 2:
Practice Address - City:KILL DEVIL HILLS
Practice Address - State:NC
Practice Address - Zip Code:27948
Practice Address - Country:US
Practice Address - Phone:252-261-5868
Practice Address - Fax:252-441-7793
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-02
Last Update Date:2013-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2002-0059208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC018V5OtherBC BS NC
2328360Medicare ID - Type UnspecifiedMEDICARE GROUP NUMBER