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Add a Practitioner
Help Grow Our Directory:
Nominate a practitioner familiar with
Arachnoiditis
or related neurologic conditions below. All submissions are reviewed and verified before inclusion. Thank you! ACMCRN.ORG
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Your Name
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Physician/Provider Full Name
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Clinic or Practice Name
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Provider Location
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Phone Number (if known)
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Physicians Email Address
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Website URL
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This provider has experience with
(select all that apply):
Treating Arachnoiditis
Diagnosing Arachnoiditis
Surgeon
Unsure
Provider Specialty
(check all that apply, optional
)
Pain Management
Neurology
Neurosurgery
Orthopedic Spine Surgery
Physical Medicine & Rehabilitation (PM&R)
Anesthesiology / Interventional Pain
Radiology / Neuroradiology
Primary Care / Internal Medicine / Family Medicine
Physical Therapy
Rheumatology
Other:
Would you like to share anything about your experience with this provider?
(For example: supportive of Arachnoiditis patients, willing to learn about Arachnoiditis,familiar with Dr. Tennant’s protocols, etc.)
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