Provider Demographics
NPI:1770913279
Name:CONCORDIA REGIONAL PAIN SERVICE, LLC
Entity type:Organization
Organization Name:CONCORDIA REGIONAL PAIN SERVICE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JARROD
Authorized Official - Middle Name:
Authorized Official - Last Name:HUEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:404-478-8785
Mailing Address - Street 1:3475 LENOX RD NE
Mailing Address - Street 2:SUITE 655
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30326-3227
Mailing Address - Country:US
Mailing Address - Phone:404-478-8785
Mailing Address - Fax:
Practice Address - Street 1:2700 LIGHTHOUSE PT E
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21224-4777
Practice Address - Country:US
Practice Address - Phone:443-599-4400
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CONCORDIA ANESTHESIOLOGY, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-11-19
Last Update Date:2014-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty