Provider Demographics
NPI:1982669339
Name:ADVANCED INTERVENTIONAL PAIN MANAGEMENT, PA
Entity Type:Organization
Organization Name:ADVANCED INTERVENTIONAL PAIN MANAGEMENT, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO, PRACTICE ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:JOHNETTE
Authorized Official - Middle Name:CAROL
Authorized Official - Last Name:SHULTZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:336-714-6406
Mailing Address - Street 1:160 KIMEL FOREST DR
Mailing Address - Street 2:SUITE 100
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27103-6074
Mailing Address - Country:US
Mailing Address - Phone:336-714-6400
Mailing Address - Fax:336-714-6402
Practice Address - Street 1:160 KIMEL FOREST DR
Practice Address - Street 2:SUITE100
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-6074
Practice Address - Country:US
Practice Address - Phone:336-714-6400
Practice Address - Fax:336-714-6402
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-19
Last Update Date:2010-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCI915OtherPARTNERS NATIONAL HEALTH
NC7679698OtherAETNA
NC89016HCMedicaid
NC016HCOtherBLUE CROSS & BLUE SHIELD
NC607132000OtherDEPT. OF LABOR
NC607132000OtherDEPT. OF LABOR