Provider Demographics
NPI:1396053286
Name:MD PAIN CARE PC
Entity type:Organization
Organization Name:MD PAIN CARE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING DIRECT
Authorized Official - Prefix:
Authorized Official - First Name:DAWNE
Authorized Official - Middle Name:H
Authorized Official - Last Name:TUNKEL
Authorized Official - Suffix:
Authorized Official - Credentials:CPC, CMPM, CPMCN
Authorized Official - Phone:865-531-0176
Mailing Address - Street 1:1301 SIGMAN RD NE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:CONYERS
Mailing Address - State:GA
Mailing Address - Zip Code:30012-3812
Mailing Address - Country:US
Mailing Address - Phone:770-760-9360
Mailing Address - Fax:
Practice Address - Street 1:1301 SIGMAN RD NE
Practice Address - Street 2:SUITE 100
Practice Address - City:CONYERS
Practice Address - State:GA
Practice Address - Zip Code:30012-3812
Practice Address - Country:US
Practice Address - Phone:770-760-9360
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-14
Last Update Date:2013-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA332BOOOOOX332B00000X
GA1744OOOOOX174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA058DBGMMedicare PIN