Provider Demographics
NPI:1992003339
Name:INTERVENTIONAL PAIN MANAGEMENT OF LAKE NORMAN PLLC
Entity Type:Organization
Organization Name:INTERVENTIONAL PAIN MANAGEMENT OF LAKE NORMAN PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:J
Authorized Official - Last Name:EDMISTON
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:704-360-4378
Mailing Address - Street 1:170 MEDICAL PARK RD
Mailing Address - Street 2:SUITE 301
Mailing Address - City:MOORESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28117-8540
Mailing Address - Country:US
Mailing Address - Phone:704-360-4378
Mailing Address - Fax:
Practice Address - Street 1:170 MEDICAL PARK RD
Practice Address - Street 2:SUITE 301
Practice Address - City:MOORESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28117-8540
Practice Address - Country:US
Practice Address - Phone:704-360-4378
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-03-09
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC200000410208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC891269NMedicaid
NCBE5025487OtherDEA
NCBE5025487OtherDEA
NCBE5025487OtherDEA