Provider Demographics
NPI:1891806345
Name:PAIN ASSOCIATES OF SOUTH GEORGIA,LLC
Entity Type:Organization
Organization Name:PAIN ASSOCIATES OF SOUTH GEORGIA,LLC
Other - Org Name:PAIN ASSOCIATES OF SOUTH GEORGIA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:J
Authorized Official - Last Name:LUPI
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:912-267-9000
Mailing Address - Street 1:3408 TROUT STREET
Mailing Address - Street 2:
Mailing Address - City:BRUNSWICK
Mailing Address - State:GA
Mailing Address - Zip Code:31520-3622
Mailing Address - Country:US
Mailing Address - Phone:912-267-9000
Mailing Address - Fax:912-267-9028
Practice Address - Street 1:3408 TROUT STREET
Practice Address - Street 2:
Practice Address - City:BRUNSWICK
Practice Address - State:GA
Practice Address - Zip Code:31520-3622
Practice Address - Country:US
Practice Address - Phone:912-267-9000
Practice Address - Fax:912-267-9028
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2010-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA208VP0014X
GA038152208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GADC0767OtherRR MEDICARE GROUP
GADC0767OtherRR MEDICARE GROUP