Provider Demographics
NPI:1609427939
Name:TRI STATE INTERVENTIONAL PAIN CLINIC PLLC
Entity Type:Organization
Organization Name:TRI STATE INTERVENTIONAL PAIN CLINIC PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE PROPRIETOR
Authorized Official - Prefix:DR
Authorized Official - First Name:CAROL
Authorized Official - Middle Name:J
Authorized Official - Last Name:MCCOURT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:901-219-6740
Mailing Address - Street 1:3450 LAKE POINTE
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38125-8842
Mailing Address - Country:US
Mailing Address - Phone:901-219-6740
Mailing Address - Fax:
Practice Address - Street 1:310 JUDGE SMITH DR
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:AR
Practice Address - Zip Code:72364-2220
Practice Address - Country:US
Practice Address - Phone:901-603-8555
Practice Address - Fax:901-730-1229
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-09-27
Last Update Date:2019-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain MedicineGroup - Multi-Specialty