Provider Demographics
NPI:1750649315
Name:COOKVILLE PAIN CONSULTANTS OF PUTNAM COUNTY
Entity Type:Organization
Organization Name:COOKVILLE PAIN CONSULTANTS OF PUTNAM COUNTY
Other - Org Name:PAIN CONSULTANTS OF PUTNAM COUNTY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CHARLOTTE
Authorized Official - Middle Name:D
Authorized Official - Last Name:MARKS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:931-952-4910
Mailing Address - Street 1:P O BOX 4129
Mailing Address - Street 2:
Mailing Address - City:COOKEVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:38502
Mailing Address - Country:US
Mailing Address - Phone:931-526-7104
Mailing Address - Fax:931-526-7105
Practice Address - Street 1:580 S JEFFERSON AVE
Practice Address - Street 2:
Practice Address - City:COOKEVILLE
Practice Address - State:TN
Practice Address - Zip Code:38501-4010
Practice Address - Country:US
Practice Address - Phone:931-526-7104
Practice Address - Fax:931-526-7105
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-01
Last Update Date:2012-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN207Q00000X, 208VP0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain MedicineGroup - Single Specialty