NPIMap

Organization Active NPI

Interventional Pain Specialists of Georgia LLC

  • Interventional Pain Medicine Physician
  • Cartersville, GA
National Provider Identifier
1205698396
Registry record updated Jun 3, 2024
On this page

Key facts

NPPES NPI Registry
Primary specialty
Interventional Pain Medicine PhysicianTaxonomy code 208VP0014X
Legal business name
INTERVENTIONAL PAIN SPECIALISTS OF GEORGIA LLC
Practice address
650 Henderson Dr Ste 409
Cartersville, GA 30120-3758
Phone
(470) 274-2800
Fax
(800) 501-3088
NPI assigned
Jan 25, 2024
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jun 3, 2024

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Sackdinanh Nok Keomahathai, MDNPI 1083775670
Title
Owner
Phone
(470) 274-2800

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Interventional Pain Medicine PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 208VP0014X Primary

Addresses

Primary practice location

650 Henderson Dr Ste 409
Cartersville, GA 30120-3758

Mailing address

650 Henderson Dr Ste 409
Cartersville, GA 30120-3758

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in GA

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20240312002841 GA Part B Supplier - Clinic/Group Practice 6709222730 Receives reassigned benefits from 2 practitioners
Practice locations: Cartersville, GA

National Provider Directory

National Provider Directory

Locations

650 Henderson Dr
Ste 409
Cartersville, GA 30120
Phone (470) 274-2800

Practitioners & affiliated clinicians

Practitioners 5

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1706140800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1717372800000",
    "number": "1205698396",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "650 HENDERSON DR STE 409",
            "city": "CARTERSVILLE",
            "state": "GA",
            "postal_code": "301203758"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "650 HENDERSON DR STE 409",
            "city": "CARTERSVILLE",
            "state": "GA",
            "postal_code": "301203758",
            "telephone_number": "470-274-2800",
            "fax_number": "800-501-3088"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "INTERVENTIONAL PAIN SPECIALISTS OF GEORGIA LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2024-01-25",
        "last_updated": "2024-06-03",
        "certification_date": "2024-06-03",
        "status": "A",
        "authorized_official_last_name": "KEOMAHATHAI",
        "authorized_official_first_name": "SACKDINANH",
        "authorized_official_middle_name": "NOK",
        "authorized_official_title_or_position": "OWNER",
        "authorized_official_telephone_number": "470-274-2800",
        "authorized_official_credential": "MD"
    },
    "taxonomies": [
        {
            "code": "208VP0014X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Pain Medicine, Interventional Pain Medicine",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Cartersville, GA

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jun 3, 2024; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.