Provider Demographics
NPI:1194833970
Name:SOUTHEAST REGIONAL PAIN CTR PC
Entity type:Organization
Organization Name:SOUTHEAST REGIONAL PAIN CTR PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:
Authorized Official - Last Name:BARNGROVER
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:706-571-7246
Mailing Address - Street 1:PO BOX 7757
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31908-7757
Mailing Address - Country:US
Mailing Address - Phone:706-571-7246
Mailing Address - Fax:706-563-8287
Practice Address - Street 1:5669 WHITESVILLE ROAD
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31904
Practice Address - Country:US
Practice Address - Phone:706-571-7246
Practice Address - Fax:706-571-8820
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-29
Last Update Date:2017-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA027027208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000296777EMedicaid
05BD0CDMedicare ID - Type Unspecified
GA000296777EMedicaid
GA6311670001Medicare NSC