Provider Demographics
NPI:1982948139
Name:INNOVATIVE PAIN MANAGEMENT CENTER LLC
Entity Type:Organization
Organization Name:INNOVATIVE PAIN MANAGEMENT CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:DR
Authorized Official - First Name:OSCAR
Authorized Official - Middle Name:JAMESON
Authorized Official - Last Name:STOKES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:323-316-8090
Mailing Address - Street 1:1300 UPPER HEMBREE RD
Mailing Address - Street 2:BUILDING 100, SUITE B
Mailing Address - City:ROSWELL
Mailing Address - State:GA
Mailing Address - Zip Code:30076-0927
Mailing Address - Country:US
Mailing Address - Phone:770-817-7951
Mailing Address - Fax:770-817-7975
Practice Address - Street 1:1300 UPPER HEMBREE RD
Practice Address - Street 2:BUILDING 100, SUITE B
Practice Address - City:ROSWELL
Practice Address - State:GA
Practice Address - Zip Code:30076-0927
Practice Address - Country:US
Practice Address - Phone:770-817-7951
Practice Address - Fax:770-817-7975
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-11-11
Last Update Date:2014-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA066905207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
6892920001Medicare NSC