Provider Demographics
NPI:1952346793
Name:PIEDMONT INTERVENTIONAL PAIN CARE, PA
Entity Type:Organization
Organization Name:PIEDMONT INTERVENTIONAL PAIN CARE, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:BRUCE
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:II
Authorized Official - Credentials:MD
Authorized Official - Phone:704-797-0065
Mailing Address - Street 1:PO BOX 72
Mailing Address - Street 2:
Mailing Address - City:SPENCER
Mailing Address - State:NC
Mailing Address - Zip Code:28159-0072
Mailing Address - Country:US
Mailing Address - Phone:704-797-0065
Mailing Address - Fax:704-797-0067
Practice Address - Street 1:320 JAKE ALEXANDER BLVD W
Practice Address - Street 2:SUITE 103
Practice Address - City:SALISBURY
Practice Address - State:NC
Practice Address - Zip Code:28147-1442
Practice Address - Country:US
Practice Address - Phone:704-797-0065
Practice Address - Fax:704-797-0067
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-17
Last Update Date:2008-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9601527207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5902363Medicaid
NC5902363Medicaid