Provider Demographics
NPI:1659943108
Name:RISE UP ADDICTION MEDICINE & PAIN MANAGEMENT PLLC
Entity Type:Organization
Organization Name:RISE UP ADDICTION MEDICINE & PAIN MANAGEMENT PLLC
Other - Org Name:MEDICAL OFFICE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:ROYALL
Authorized Official - Suffix:JR
Authorized Official - Credentials:FNP
Authorized Official - Phone:336-248-1068
Mailing Address - Street 1:500 W 5TH ST STE 800
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27101-3131
Mailing Address - Country:US
Mailing Address - Phone:336-247-1068
Mailing Address - Fax:
Practice Address - Street 1:500 W 5TH ST STE 800
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27101-3131
Practice Address - Country:US
Practice Address - Phone:336-247-1068
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-07-14
Last Update Date:2021-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207LA0401XAllopathic & Osteopathic PhysiciansAnesthesiologyAddiction MedicineGroup - Single Specialty
No207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1356819320Medicaid