Provider Demographics
NPI:1629460381
Name:ATLANTIC COAST PAIN SPECIALISTS, INC
Entity Type:Organization
Organization Name:ATLANTIC COAST PAIN SPECIALISTS, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:BLAKE
Authorized Official - Last Name:KLINE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:843-438-8470
Mailing Address - Street 1:2767 CULTRA RD
Mailing Address - Street 2:
Mailing Address - City:CONWAY
Mailing Address - State:SC
Mailing Address - Zip Code:29526-3716
Mailing Address - Country:US
Mailing Address - Phone:843-438-8470
Mailing Address - Fax:843-438-8480
Practice Address - Street 1:2767 CULTRA RD
Practice Address - Street 2:
Practice Address - City:CONWAY
Practice Address - State:SC
Practice Address - Zip Code:29526-3716
Practice Address - Country:US
Practice Address - Phone:843-438-8470
Practice Address - Fax:843-438-8480
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-03-04
Last Update Date:2022-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207L00000X, 207LP2900X, 207QA0505X, 225100000X, 332B00000X, 363AM0700X
SC20364207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain MedicineGroup - Single Specialty
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Multi-Specialty
No207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult MedicineGroup - Multi-Specialty
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Multi-Specialty
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC203648Medicaid
SCG21460Medicare UPIN
SC203648Medicaid