Basic Information
| Provider Information | |||||||||
| NPI: | 1568121846 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CONSULTANTS IN PAIN MEDICINE, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10475 CENTURION PKWY N STE 201 | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322565004 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9042233321 | ||||||||
| FaxNumber: | 9042232169 | ||||||||
| Practice Location | |||||||||
| Address1: | 200 BLUE MOON XING STE 203 | ||||||||
| Address2: | |||||||||
| City: | POOLER | ||||||||
| State: | GA | ||||||||
| PostalCode: | 313229698 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9042233321 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/14/2021 | ||||||||
| LastUpdateDate: | 12/14/2021 | ||||||||
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| AuthorizedOfficialLastName: | GROTH | ||||||||
| AuthorizedOfficialFirstName: | ALICIA | ||||||||
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| AuthorizedOfficialTitleorPosition: | CREDENTIALING | ||||||||
| AuthorizedOfficialTelephone: | 9042233321 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | CONSULTANTS IN PAIN MEDICINE, LLC | ||||||||
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| NPICertificationDate: | 12/14/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208VP0014X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pain Medicine | Interventional Pain Medicine |
No ID Information.