Provider Demographics
NPI:1588994685
Name:SOUTHEASTERN INTERVENTIONAL PAIN ASC LLC
Entity type:Organization
Organization Name:SOUTHEASTERN INTERVENTIONAL PAIN ASC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ANKUR
Authorized Official - Middle Name:
Authorized Official - Last Name:PATEL
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:678-971-4167
Mailing Address - Street 1:PO BOX 37580
Mailing Address - Street 2:
Mailing Address - City:BELFAST
Mailing Address - State:ME
Mailing Address - Zip Code:04915-1217
Mailing Address - Country:US
Mailing Address - Phone:888-488-8289
Mailing Address - Fax:502-919-9780
Practice Address - Street 1:1150 HAMMOND DR NE
Practice Address - Street 2:LL 50
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30328
Practice Address - Country:US
Practice Address - Phone:678-971-4167
Practice Address - Fax:678-971-4168
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-01-12
Last Update Date:2024-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALNR-ASC2014-023261QA1903X
261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA202G498226OtherMEDICARE