Provider Demographics
NPI:1750789947
Name:SELECT INTERVENTIONAL PAIN, PC
Entity type:Organization
Organization Name:SELECT INTERVENTIONAL PAIN, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DERRELL
Authorized Official - Middle Name:L
Authorized Official - Last Name:LEGGETT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:470-251-5300
Mailing Address - Street 1:794 MCDONOUGH RD
Mailing Address - Street 2:SUITE 108
Mailing Address - City:JACKSON
Mailing Address - State:GA
Mailing Address - Zip Code:30233-1572
Mailing Address - Country:US
Mailing Address - Phone:470-251-5300
Mailing Address - Fax:470-251-5301
Practice Address - Street 1:794 MCDONOUGH RD
Practice Address - Street 2:SUITE 108
Practice Address - City:JACKSON
Practice Address - State:GA
Practice Address - Zip Code:30233-1572
Practice Address - Country:US
Practice Address - Phone:470-251-5300
Practice Address - Fax:470-251-5301
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-12-20
Last Update Date:2017-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA60125BMedicare UPIN