1285182659 NPI number — FLORIDA PAIN SPECIALISTS PLLC

Table of content: (NPI 1285182659)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1285182659 NPI number — FLORIDA PAIN SPECIALISTS PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FLORIDA PAIN SPECIALISTS PLLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1285182659
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/13/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4100 SOUTHPOINT DR E STE 1
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JACKSONVILLE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32216-8710
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
46-475-2669
Provider Business Mailing Address Fax Number:
904-770-5594

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4100 SOUTHPOINT DR E STE 1
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JACKSONVILLE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32216-8710
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
46-475-2669
Provider Business Practice Location Address Fax Number:
904-770-5594
Provider Enumeration Date:
09/14/2016

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
RILEY
Authorized Official First Name:
SHANNON
Authorized Official Middle Name:
Authorized Official Title or Position:
VP OF OPERATIONS
Authorized Official Telephone Number:
904-647-5266

Provider Taxonomy Codes

  • Taxonomy code: 2081P2900X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2081S0010X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208VP0014X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 261QP3300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 314000000X , with the licence number: PA9105187 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 314000000X , with the licence number: ME117856 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1487954723 . This is a "NPI" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 1578898524 . This is a "NPI" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".