Provider Demographics
NPI:1336527191
Name:PALMETTO PAIN MANAGEMENT OF GA, LLC
Entity Type:Organization
Organization Name:PALMETTO PAIN MANAGEMENT OF GA, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:HODGE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:803-779-3263
Mailing Address - Street 1:1655 BERNARDIN AVE
Mailing Address - Street 2:SUITE 240
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29204-2039
Mailing Address - Country:US
Mailing Address - Phone:803-779-3263
Mailing Address - Fax:
Practice Address - Street 1:5745 CLARION ST
Practice Address - Street 2:
Practice Address - City:CUMMING
Practice Address - State:GA
Practice Address - Zip Code:30040-0305
Practice Address - Country:US
Practice Address - Phone:803-779-3263
Practice Address - Fax:803-779-3207
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PALMETTO PAIN MANAGEMENT, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-05-13
Last Update Date:2015-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA71017207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAD29692Medicare UPIN
SCB19429Medicare UPIN