Provider Demographics
NPI:1942486832
Name:EAST GEORGIA PAIN MANAGEMENT CENTER
Entity Type:Organization
Organization Name:EAST GEORGIA PAIN MANAGEMENT CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:TOVIE
Authorized Official - Middle Name:NICHOLE
Authorized Official - Last Name:DUKE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-784-3862
Mailing Address - Street 1:4119 TATE ST NE
Mailing Address - Street 2:
Mailing Address - City:COVINGTON
Mailing Address - State:GA
Mailing Address - Zip Code:30014-2554
Mailing Address - Country:US
Mailing Address - Phone:770-784-3862
Mailing Address - Fax:770-784-5989
Practice Address - Street 1:4119 TATE ST NE
Practice Address - Street 2:
Practice Address - City:COVINGTON
Practice Address - State:GA
Practice Address - Zip Code:30014-2554
Practice Address - Country:US
Practice Address - Phone:770-784-3862
Practice Address - Fax:770-784-5989
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-10
Last Update Date:2008-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA052044174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAH72075Medicare UPIN
GAGRP7108Medicare PIN