Provider Demographics
NPI:1255820502
Name:GEORGIA PAIN AND SPINE SOLUTIONS, PC
Entity type:Organization
Organization Name:GEORGIA PAIN AND SPINE SOLUTIONS, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:
Authorized Official - First Name:MARCUS
Authorized Official - Middle Name:Q
Authorized Official - Last Name:POLK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:404-403-4567
Mailing Address - Street 1:P.O. BOX 370160
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30037-0160
Mailing Address - Country:US
Mailing Address - Phone:404-403-4567
Mailing Address - Fax:404-920-8185
Practice Address - Street 1:76 HIGHLAND PAVILION COURT
Practice Address - Street 2:#133
Practice Address - City:HIRAM
Practice Address - State:GA
Practice Address - Zip Code:30141-3170
Practice Address - Country:US
Practice Address - Phone:800-533-8210
Practice Address - Fax:404-745-8013
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-05-02
Last Update Date:2020-04-28
Deactivation Date:2019-07-19
Deactivation Code:
Reactivation Date:2019-07-26
Provider Licenses
StateLicense IDTaxonomies
GA040758207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003159967JMedicaid