Basic Information
| Provider Information | |||||||||
| NPI: | 1558666149 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PAINSTOP SPINE CLINIC, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 4594 | ||||||||
| Address2: | |||||||||
| City: | BILOXI | ||||||||
| State: | MS | ||||||||
| PostalCode: | 395354594 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2282734096 | ||||||||
| FaxNumber: | 2285941765 | ||||||||
| Practice Location | |||||||||
| Address1: | 3003 SHORTCUT RD | ||||||||
| Address2: | |||||||||
| City: | PASCAGOULA | ||||||||
| State: | MS | ||||||||
| PostalCode: | 395671810 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2282734096 | ||||||||
| FaxNumber: | 2285941765 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/13/2011 | ||||||||
| LastUpdateDate: | 01/07/2020 | ||||||||
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| AuthorizedOfficialLastName: | TSANG | ||||||||
| AuthorizedOfficialFirstName: | STACEY | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | GENERAL MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 6265126348 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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| NPICertificationDate: | 01/07/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 208VP0014X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pain Medicine | Interventional Pain Medicine |
ID Information
| ID | Type | State | Issuer | Description | 00057070 | 05 | MS | MEDICAID | 30270G0134 | 01 | MS | MCR PTAN GROUP | OTHER | DT9919 | 01 | MS | RAILROAD MEDICARE, GROUP PTAN | OTHER |