Provider Demographics
NPI:1639190994
Name:PHYSICIAN PAIN SPECIALISTS, P.C.
Entity Type:Organization
Organization Name:PHYSICIAN PAIN SPECIALISTS, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:DIANNE
Authorized Official - Middle Name:S
Authorized Official - Last Name:THISTLETHWAITE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:404-257-1415
Mailing Address - Street 1:5671 PEACHTREE DUNWOODY ROAD, N.E.
Mailing Address - Street 2:SUITE 610
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30342-5000
Mailing Address - Country:US
Mailing Address - Phone:404-257-1415
Mailing Address - Fax:404-851-1649
Practice Address - Street 1:5671 PEACHTREE DUNWOODY RD NE
Practice Address - Street 2:SUITE 660
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30342-5000
Practice Address - Country:US
Practice Address - Phone:404-256-5405
Practice Address - Fax:404-303-1418
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-22
Last Update Date:2015-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAGRP 2824Medicare ID - Type UnspecifiedMEDICARE GROUP NUMBER