Provider Demographics
NPI:1407373210
Name:PHYSICIAN ASSOCIATE INTERDISCIPLINARY CLINIC (PAIN-C)
Entity type:Organization
Organization Name:PHYSICIAN ASSOCIATE INTERDISCIPLINARY CLINIC (PAIN-C)
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT / CEO
Authorized Official - Prefix:
Authorized Official - First Name:MAURICE
Authorized Official - Middle Name:
Authorized Official - Last Name:SKILLERN
Authorized Official - Suffix:
Authorized Official - Credentials:DMS, PA-C
Authorized Official - Phone:706-536-3272
Mailing Address - Street 1:4131 KIRBY PKWY STE 1
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38115-6500
Mailing Address - Country:US
Mailing Address - Phone:706-536-3272
Mailing Address - Fax:
Practice Address - Street 1:4131 KIRBY PKWY STE 1
Practice Address - Street 2:KIRBY-RAINES MEDICAL CENTER
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38115-3206
Practice Address - Country:US
Practice Address - Phone:706-536-3272
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-08-23
Last Update Date:2021-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN1805363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1407373210OtherCLINIC NPI NUMBER