Provider Demographics
NPI:1750494423
Name:GEORGIA PAIN SPINE CENTER
Entity Type:Organization
Organization Name:GEORGIA PAIN SPINE CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:VICTORIA
Authorized Official - Middle Name:
Authorized Official - Last Name:BECK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:404-403-8310
Mailing Address - Street 1:PO BOX 11407 DEPT 2657
Mailing Address - Street 2:
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35246-0001
Mailing Address - Country:US
Mailing Address - Phone:770-920-4950
Mailing Address - Fax:770-929-9092
Practice Address - Street 1:15 MEDICAL DRIVE
Practice Address - Street 2:SUITE 302
Practice Address - City:CARTERSVILLE
Practice Address - State:GA
Practice Address - Zip Code:30121
Practice Address - Country:US
Practice Address - Phone:678-337-3163
Practice Address - Fax:770-422-7306
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-16
Last Update Date:2020-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QA1903X
GA008-311261QP3300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
No261QP3300XAmbulatory Health Care FacilitiesClinic/CenterPain
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA5665923OtherCCN AND FIRST HEALTH
GA111263ASCAMedicare ID - Type Unspecified