Provider Demographics
NPI:1992292973
Name:ADVANCED SPINE & PAIN INTERVENTIONS LLC - JASPER
Entity type:Organization
Organization Name:ADVANCED SPINE & PAIN INTERVENTIONS LLC - JASPER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOER
Authorized Official - Prefix:
Authorized Official - First Name:WOODLEY
Authorized Official - Middle Name:
Authorized Official - Last Name:MARDY-DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:470-299-1998
Mailing Address - Street 1:12389 CRABAPPLE RD
Mailing Address - Street 2:
Mailing Address - City:ALPHARETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30004-6328
Mailing Address - Country:US
Mailing Address - Phone:470-299-1998
Mailing Address - Fax:470-299-1898
Practice Address - Street 1:49 GORDON RD
Practice Address - Street 2:SUITE 102
Practice Address - City:JASPER
Practice Address - State:GA
Practice Address - Zip Code:30143-1017
Practice Address - Country:US
Practice Address - Phone:470-299-1998
Practice Address - Fax:470-299-1898
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ADVANCED SPINE & PAIN INTERVENTIONS LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-04-16
Last Update Date:2024-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA059463207LA0401X, 208VP0014X
GAPHRE0101613336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain MedicineGroup - Multi-Specialty
No207LA0401XAllopathic & Osteopathic PhysiciansAnesthesiologyAddiction MedicineGroup - Multi-Specialty
No3336C0003XSuppliersPharmacyCommunity/Retail PharmacyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA6004576980Medicaid