Provider Demographics
NPI:1609815562
Name:PIEDMONT COMPREHENSIVE PAIN MANAGEMENT GROUP LLC
Entity Type:Organization
Organization Name:PIEDMONT COMPREHENSIVE PAIN MANAGEMENT GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:GENNA
Authorized Official - Middle Name:
Authorized Official - Last Name:LYNN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:864-269-4416
Mailing Address - Street 1:100 HEALTHY WAY
Mailing Address - Street 2:SUITE 1260
Mailing Address - City:ANDERSON
Mailing Address - State:SC
Mailing Address - Zip Code:29621-2067
Mailing Address - Country:US
Mailing Address - Phone:864-225-3551
Mailing Address - Fax:864-328-0328
Practice Address - Street 1:100 HEALTHY WAY
Practice Address - Street 2:SUITE 1260
Practice Address - City:ANDERSON
Practice Address - State:SC
Practice Address - Zip Code:29621
Practice Address - Country:US
Practice Address - Phone:864-225-3551
Practice Address - Fax:864-328-0328
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-06
Last Update Date:2018-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC19980208VP0000X
SC19467208VP0014X
SC20828208VP0014X
SC28639208VP0014X
332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain MedicineGroup - Multi-Specialty
No208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain MedicineGroup - Multi-Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP2340Medicaid
SCGP2340Medicaid