Provider Demographics
NPI:1902852130
Name:CONSULTANTS IN PAIN MEDICINE, LLC
Entity Type:Organization
Organization Name:CONSULTANTS IN PAIN MEDICINE, LLC
Other - Org Name:CENTURION SPINE & PAIN CENTERS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:ALICIA
Authorized Official - Middle Name:
Authorized Official - Last Name:GROTH (AO)
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:904-223-3321
Mailing Address - Street 1:5191 FIRST COAST TECH PKWY FL 3
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32224-0609
Mailing Address - Country:US
Mailing Address - Phone:904-256-2754
Mailing Address - Fax:904-223-2169
Practice Address - Street 1:3408 TROUT ST
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:912-466-9111
Practice Address - Fax:912-466-0366
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-26
Last Update Date:2023-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA041205207L00000X, 207LP2900X, 208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain MedicineGroup - Multi-Specialty
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Multi-Specialty
No207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA6400190003Medicare NSC
GA6400190003OtherDME PTAN