Provider Demographics
NPI:1710156393
Name:JEFFERSON PAIN CLINIC INC
Entity Type:Organization
Organization Name:JEFFERSON PAIN CLINIC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:AHMAD
Authorized Official - Middle Name:
Authorized Official - Last Name:GHADAMYARI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:706-387-0027
Mailing Address - Street 1:PO BOX 680904
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30068-0016
Mailing Address - Country:US
Mailing Address - Phone:706-387-0027
Mailing Address - Fax:706-387-0073
Practice Address - Street 1:1351 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:JEFFERSON
Practice Address - State:GA
Practice Address - Zip Code:30549-2879
Practice Address - Country:US
Practice Address - Phone:706-387-0027
Practice Address - Fax:706-387-0073
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-27
Last Update Date:2008-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA032558208VP0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain MedicineGroup - Single Specialty