Provider Demographics
NPI:1992217723
Name:SOUTHEASTERN PAIN PLLC
Entity Type:Organization
Organization Name:SOUTHEASTERN PAIN PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GARY
Authorized Official - Middle Name:CHASE
Authorized Official - Last Name:BLACK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:770-548-2182
Mailing Address - Street 1:3671 BURNING BUSH RD
Mailing Address - Street 2:
Mailing Address - City:RINGGOLD
Mailing Address - State:GA
Mailing Address - Zip Code:30736-5725
Mailing Address - Country:US
Mailing Address - Phone:770-548-2182
Mailing Address - Fax:
Practice Address - Street 1:1236 KNOXVILLE HWY
Practice Address - Street 2:
Practice Address - City:WARTBURG
Practice Address - State:TN
Practice Address - Zip Code:37887
Practice Address - Country:US
Practice Address - Phone:770-548-2182
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-11-02
Last Update Date:2018-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN0099OtherMEDICARE PTAN
TNQ035114Medicaid
TNDY2044OtherRRMEDICARE PTAN