Provider Demographics
NPI:1538557780
Name:SC PAIN AND SPINE SPECIALIST
Entity type:Organization
Organization Name:SC PAIN AND SPINE SPECIALIST
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:JASON
Authorized Official - Middle Name:C
Authorized Official - Last Name:ROSENBERG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:843-839-7246
Mailing Address - Street 1:4731 HWY 17 BYPASS S
Mailing Address - Street 2:
Mailing Address - City:MURRELLS INLET
Mailing Address - State:SC
Mailing Address - Zip Code:29576
Mailing Address - Country:US
Mailing Address - Phone:843-839-7246
Mailing Address - Fax:843-839-7323
Practice Address - Street 1:230 S FRASER STREET
Practice Address - Street 2:
Practice Address - City:GEORGETOWN
Practice Address - State:SC
Practice Address - Zip Code:29440
Practice Address - Country:US
Practice Address - Phone:843-461-4735
Practice Address - Fax:843-839-7323
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SC PAIN AND SPINE SPECIALIST, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-12-22
Last Update Date:2015-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC24751208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCA278Medicare UPIN