Provider Demographics
NPI:1922387687
Name:PAIN & PALLIATIVE CARE CENTER OF ATLANTA
Entity Type:Organization
Organization Name:PAIN & PALLIATIVE CARE CENTER OF ATLANTA
Other - Org Name:PAIN & PALLIATIVE CARE CENTER OF ATLANTA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:D
Authorized Official - Last Name:GOODLOW
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:678-596-2227
Mailing Address - Street 1:2624 SAINT PAUL DR
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30331
Mailing Address - Country:US
Mailing Address - Phone:678-596-2227
Mailing Address - Fax:770-603-1122
Practice Address - Street 1:2624 SAINT PAUL DR
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30331
Practice Address - Country:US
Practice Address - Phone:678-596-2227
Practice Address - Fax:770-603-1122
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-12
Last Update Date:2011-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA057977207LH0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207LH0002XAllopathic & Osteopathic PhysiciansAnesthesiologyHospice and Palliative MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAI63669Medicare UPIN