Provider Demographics
NPI:1811098874
Name:LAUREL PAIN CLINIC PA
Entity type:Organization
Organization Name:LAUREL PAIN CLINIC PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING SUPERVISOR
Authorized Official - Prefix:
Authorized Official - First Name:ASHLEY
Authorized Official - Middle Name:N
Authorized Official - Last Name:BUIE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-898-7530
Mailing Address - Street 1:1706 W 12TH ST
Mailing Address - Street 2:
Mailing Address - City:LAUREL
Mailing Address - State:MS
Mailing Address - Zip Code:39440-2559
Mailing Address - Country:US
Mailing Address - Phone:601-369-2021
Mailing Address - Fax:
Practice Address - Street 1:1706 W 12TH ST
Practice Address - Street 2:
Practice Address - City:LAUREL
Practice Address - State:MS
Practice Address - Zip Code:39440-2559
Practice Address - Country:US
Practice Address - Phone:601-369-2021
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-25
Last Update Date:2012-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS16318208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09987586Medicaid
MSDF1770OtherRAILROAD MEDICARE
MSCO3320Medicare ID - Type Unspecified