Provider Demographics
NPI:1336201664
Name:MD PAIN CARE, P.C.
Entity Type:Organization
Organization Name:MD PAIN CARE, P.C.
Other - Org Name:COVINGTON ANESTHESIA ASSOCIATES
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:R
Authorized Official - Middle Name:L
Authorized Official - Last Name:TALLEY
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:770-760-9360
Mailing Address - Street 1:1622 MARS HILL RD
Mailing Address - Street 2:STE C
Mailing Address - City:WATKINSVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30677-4893
Mailing Address - Country:US
Mailing Address - Phone:706-769-9633
Mailing Address - Fax:706-769-9309
Practice Address - Street 1:1301 SIGMAN RD
Practice Address - Street 2:SUITE 100
Practice Address - City:CONYERS
Practice Address - State:GA
Practice Address - Zip Code:30012-4515
Practice Address - Country:US
Practice Address - Phone:770-760-9360
Practice Address - Fax:770-760-9303
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-14
Last Update Date:2012-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA300028514Medicaid
GAGRP254Medicare PIN