SOUTHERN INTERVENTIONAL PAIN CENTER LLC – Interventional Pain Medicine Physician, NPI 1063971596
Interventional Pain Medicine Physician
Main info
Profile Insights
NPPES metrics only — not quality of care.
Provider Addresses for SOUTHERN INTERVENTIONAL PAIN CENTER LLC
619 SW BAYA DR STE 102
LAKE CITY, FL 320254204
Phone: (386) 361-3400
Fax: (855) 313-1262
Type: Location
615, South Hansell Street, McLoughlin Heights, Thomasville, Thomas County, Georgia, 31792, United States
THOMASVILLE, GA 317925556
Phone: (229) 226-2234
Fax: (229) 226-2237
Type: Mailing
NPPES updates history
No NPPES updates recorded for this provider.
Prescription Activity
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Open Payments (CMS)
No Open Payments data available for this provider.
This can happen when there are no reportable CMS Open Payments records.
Medicare Enrollment & Revalidation
Source: CMS public data · Not endorsed by CMS ·
Educational use only—not medical, billing, or legal advice.
PECOS enrollment status
Participating (accepts Medicare assignment)
Enrollment effective: 2019-03-22
PECOS data refreshed: 2026-05-27
Medicare revalidation (CMS due date list)
Due date not assigned yet
CMS is tracking this Medicare enrollment for revalidation, but has not published a due date.
Enrollment records
1
Earliest due date
Not assigned (TBD)
CMS data updated
2026-06-01
Revalidation progress
- Medicare enrolled
- On CMS revalidation list
- Due date assigned
- Revalidate in PECOS
CMS enrollment records
| Enrollment ID | Type | Specialty | State | Due date |
|---|---|---|---|---|
| O20190322001312 | O | Physician - Physical And Rehabilitation | FL | TBD |
What to do next
- No action required while the due date shows TBD.
- Check the CMS Revalidation Lookup Tool periodically — CMS updates the list about every 60 days.
- Do not submit a revalidation application in PECOS until CMS publishes a concrete due date.
Prepare CMS-855 application → · Look up this NPI in PECOS → · Verify on CMS PECOS
Medicare Utilization (FFS)
Source: CMS public data · Not endorsed by CMS · Beneficiary counts under 11 are suppressed in source data ·
Educational use only—not medical, billing, or legal advice.
No Medicare fee-for-service utilization data available for this provider in our database.
Insurance plans in this area (ZIP 32025)
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