Provider Demographics
NPI:1962627588
Name:PREMIER INTERVENTIONAL PAIN MANAGEMENT & ANESTHESIOLOGY, P.A.
Entity Type:Organization
Organization Name:PREMIER INTERVENTIONAL PAIN MANAGEMENT & ANESTHESIOLOGY, P.A.
Other - Org Name:PREMIER PAIN MANAGEMENT
Other - Org Type:Other Name
Authorized Official - Title/Position:OFFICER
Authorized Official - Prefix:DR
Authorized Official - First Name:SUNIL
Authorized Official - Middle Name:TERRY
Authorized Official - Last Name:PERSAUD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:229-293-9555
Mailing Address - Street 1:4060 KILARNEY CIR
Mailing Address - Street 2:
Mailing Address - City:VALDOSTA
Mailing Address - State:GA
Mailing Address - Zip Code:31602-0815
Mailing Address - Country:US
Mailing Address - Phone:229-293-9555
Mailing Address - Fax:
Practice Address - Street 1:2406 BEMISS RD STE C
Practice Address - Street 2:
Practice Address - City:VALDOSTA
Practice Address - State:GA
Practice Address - Zip Code:31602-1996
Practice Address - Country:US
Practice Address - Phone:229-293-9555
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-17
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA048175208VP0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA=========OtherEIN#