| Southern Interventional Pain Center Llc | |
|
619 Sw Baya Dr Ste 102 Lake City FL 32025-4204 | |
| (386) 361-3400 | |
| (855) 313-1262 |
| Full Name | Southern Interventional Pain Center Llc |
|---|---|
| Speciality | Pain Medicine |
| Location | 619 Sw Baya Dr Ste 102, Lake City, Florida |
| Authorized Official Name and Position | Maximilian Shahryar Shokat (MANAGING MEMBER) |
| Authorized Official Contact | 2292262234 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| Southern Interventional Pain Center Llc 615 S Hansell St Thomasville GA 31792-5556 Ph: (229) 226-2234 | Southern Interventional Pain Center Llc 619 Sw Baya Dr Ste 102 Lake City FL 32025-4204 Ph: (386) 361-3400 |
| NPI Number | 1063971596 |
|---|---|
| Provider Enumeration Date | 03/14/2019 |
| Last Update Date | 01/31/2020 |
| Certification Date | 01/31/2020 |
| Medicare PECOS PAC ID | 9436460318 |
|---|---|
| Medicare Enrollment ID | O20190322001312 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1063971596 | NPI | - | NPPES |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 2084N0400X | Psychiatry & Neurology - Neurology | (* (Not Available)) | Secondary |
| 208VP0014X | Pain Medicine - Interventional Pain Medicine | (* (Not Available)) | Primary |
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