Provider Demographics
NPI:1831265776
Name:ALABAMA PAIN CENTER, LLC
Entity type:Organization
Organization Name:ALABAMA PAIN CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:DEAN
Authorized Official - Last Name:WILLIS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:256-882-2003
Mailing Address - Street 1:600 WHITESPORT DRIVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:HUNTSVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:35801
Mailing Address - Country:US
Mailing Address - Phone:256-882-2003
Mailing Address - Fax:256-705-4630
Practice Address - Street 1:600 WHITESPORT DRIVE
Practice Address - Street 2:SUITE A
Practice Address - City:HUNTSVILLE
Practice Address - State:AL
Practice Address - Zip Code:35801
Practice Address - Country:US
Practice Address - Phone:256-882-2003
Practice Address - Fax:256-705-4630
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-24
Last Update Date:2012-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL895103TC0700X
AL1-075145363L00000X
AL12320207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain MedicineGroup - Multi-Specialty
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL529908240Medicaid
ALI367Medicare ID - Type Unspecified