Provider Demographics
NPI:1649523689
Name:SOUTHEAST SPINE & PAIN ASSOCIATES LLC
Entity type:Organization
Organization Name:SOUTHEAST SPINE & PAIN ASSOCIATES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING/BILLING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTIE
Authorized Official - Middle Name:
Authorized Official - Last Name:LORD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:865-633-9469
Mailing Address - Street 1:PO BOX 27629
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37927-7629
Mailing Address - Country:US
Mailing Address - Phone:865-633-9469
Mailing Address - Fax:865-633-9474
Practice Address - Street 1:1718 SAINT MARY ST
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37917-4517
Practice Address - Country:US
Practice Address - Phone:865-633-9469
Practice Address - Fax:865-633-9474
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-15
Last Update Date:2015-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP3300XAmbulatory Health Care FacilitiesClinic/CenterPain
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1531106Medicaid
103G707028Medicare PIN