Organization
SOUTHEASTERN PAIN PLLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
GARY CHASE BLACK MD (OWNER)
(770) 548-2182
Entity
Organization
Contact information
Practice address
1236 KNOXVILLE HWY, WARTBURG, TN 37887
(770) 548-2182
Mailing address
3671 BURNING BUSH RD, RINGGOLD, GA 30736-5725
(770) 548-2182
Taxonomy
Speciality
Code
Description
License number
State
207LP2900X
Pain Medicine (Anesthesiology) Physician
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
0099
MEDICARE PTAN
TN
01
—
DY2044
RRMEDICARE PTAN
TN
05
—
Q035114
—
TN
Enumeration date
11/02/2017
Last updated
06/01/2018
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