Provider Demographics
NPI:1750420147
Name:INTERVENTIONAL SPINE AND PAIN MANAGEMENT AMBULATORY SURGICAL CENTER
Entity type:Organization
Organization Name:INTERVENTIONAL SPINE AND PAIN MANAGEMENT AMBULATORY SURGICAL CENTER
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MRS
Authorized Official - First Name:VICTORIA
Authorized Official - Middle Name:
Authorized Official - Last Name:BECK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:404-920-4950
Mailing Address - Street 1:PO BOX 11407 DEPT 2344
Mailing Address - Street 2:
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35246-3872
Mailing Address - Country:US
Mailing Address - Phone:770-929-9033
Mailing Address - Fax:770-929-9092
Practice Address - Street 1:1388 WELLBROOK CIR NE
Practice Address - Street 2:SUITE A
Practice Address - City:CONYERS
Practice Address - State:GA
Practice Address - Zip Code:30012-3872
Practice Address - Country:US
Practice Address - Phone:770-929-9033
Practice Address - Fax:770-929-9092
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-05
Last Update Date:2020-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA111291ASCAMedicare PIN