Provider Demographics
NPI:1609143502
Name:TOTAL DIAGNOSTIC AND INTERVENTIONAL PAIN PC
Entity Type:Organization
Organization Name:TOTAL DIAGNOSTIC AND INTERVENTIONAL PAIN PC
Other - Org Name:TDI PAIN
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:DAVIN
Authorized Official - Middle Name:GERRARD
Authorized Official - Last Name:MITCHELL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:706-845-9370
Mailing Address - Street 1:1075 LAFAYETTE PKWY
Mailing Address - Street 2:STE 100
Mailing Address - City:LAGRANGE
Mailing Address - State:GA
Mailing Address - Zip Code:30241-3584
Mailing Address - Country:US
Mailing Address - Phone:706-443-5273
Mailing Address - Fax:706-443-5275
Practice Address - Street 1:1075 LAFAYETTE PKWY
Practice Address - Street 2:STE 100
Practice Address - City:LAGRANGE
Practice Address - State:GA
Practice Address - Zip Code:30241-3584
Practice Address - Country:US
Practice Address - Phone:706-443-5273
Practice Address - Fax:706-443-5275
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-20
Last Update Date:2019-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA63786208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain MedicineGroup - Single Specialty