Basic Information
| Provider Information | |||||||||
| NPI: | 1891388211 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SPECIALTY SPINE AND PAIN PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11350 MCCORMICK ROAD | ||||||||
| Address2: | EXECUTIVE PLAZA 1, SUITE 501 | ||||||||
| City: | HUNT | ||||||||
| State: | MD | ||||||||
| PostalCode: | 210311002 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7039148000 | ||||||||
| FaxNumber: | 4103291054 | ||||||||
| Practice Location | |||||||||
| Address1: | 5005 LANIER ISLANDS PARKWAY | ||||||||
| Address2: | BUILDING B, SUITE 500 | ||||||||
| City: | BUFORD | ||||||||
| State: | GA | ||||||||
| PostalCode: | 30518 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7702977277 | ||||||||
| FaxNumber: | 7705537641 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/17/2021 | ||||||||
| LastUpdateDate: | 02/17/2021 | ||||||||
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| AuthorizedOfficialLastName: | ROBINSON | ||||||||
| AuthorizedOfficialFirstName: | HOWARD | ||||||||
| AuthorizedOfficialMiddleName: | K | ||||||||
| AuthorizedOfficialTitleorPosition: | PHYSICIAN | ||||||||
| AuthorizedOfficialTelephone: | 7702977277 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 01/25/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208VP0014X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pain Medicine | Interventional Pain Medicine |
No ID Information.