Provider Demographics
NPI:1932501277
Name:ATLANTIC PAIN CENTER
Entity Type:Organization
Organization Name:ATLANTIC PAIN CENTER
Other - Org Name:ATL PAIN INSTITUTE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:DIDURO
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:678-580-1862
Mailing Address - Street 1:PO BOX 680576
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30068-0010
Mailing Address - Country:US
Mailing Address - Phone:678-580-1862
Mailing Address - Fax:678-580-1648
Practice Address - Street 1:4535 WINTERS CHAPEL RD
Practice Address - Street 2:SUITE B
Practice Address - City:DORAVILLE
Practice Address - State:GA
Practice Address - Zip Code:30360-2705
Practice Address - Country:US
Practice Address - Phone:678-580-1862
Practice Address - Fax:678-580-1648
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-09-18
Last Update Date:2014-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA57064208VP0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain MedicineGroup - Single Specialty