Provider Demographics
NPI:1578747077
Name:COMPREHENSIVE REHABILITATION & PAIN SPECIALISTS, P.C.
Entity Type:Organization
Organization Name:COMPREHENSIVE REHABILITATION & PAIN SPECIALISTS, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:L
Authorized Official - Last Name:FULLER-HINES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:215-287-2738
Mailing Address - Street 1:135 E RICH BLVD
Mailing Address - Street 2:
Mailing Address - City:ELIZABETH CITY
Mailing Address - State:NC
Mailing Address - Zip Code:27909-5518
Mailing Address - Country:US
Mailing Address - Phone:215-287-2738
Mailing Address - Fax:252-335-2840
Practice Address - Street 1:135 E RICH BLVD
Practice Address - Street 2:
Practice Address - City:ELIZABETH CITY
Practice Address - State:NC
Practice Address - Zip Code:27909-5518
Practice Address - Country:US
Practice Address - Phone:252-333-1277
Practice Address - Fax:252-333-1877
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-20
Last Update Date:2013-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2007-00519208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5908742Medicaid
019WYOtherBCBS
NC6745110001Medicare NSC
019WYOtherBCBS