Basic Information
| Provider Information | |||||||||
| NPI: | 1053363457 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FLORIDA PAIN AND REHABILITATION ASSOCIATES INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5365 W ATLANTIC AVE | ||||||||
| Address2: | SUITE 504 | ||||||||
| City: | DELRAY BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 334848172 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5612419300 | ||||||||
| FaxNumber: | 5612419339 | ||||||||
| Practice Location | |||||||||
| Address1: | 5365 W ATLANTIC AVE | ||||||||
| Address2: | SUITE 504 | ||||||||
| City: | DELRAY BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 334848172 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5612419300 | ||||||||
| FaxNumber: | 5612419339 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/16/2006 | ||||||||
| LastUpdateDate: | 06/21/2018 | ||||||||
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| AuthorizedOfficialLastName: | SAJAN | ||||||||
| AuthorizedOfficialFirstName: | CHERIAN | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 4076225766 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208VP0014X | ME109651 | FL | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pain Medicine | Interventional Pain Medicine | 291U00000X | 800025838 | FL | N | Laboratories | Clinical Medical Laboratory | 3336C0002X | PH24372 | FL | N | Suppliers | Pharmacy | Clinic Pharmacy | 174400000X | Y | 193200000X MULTI-SPECIALTY GROUP | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 0149537-03 | 05 | FL | MEDICAID | 0149537-00 | 05 | FL | MEDICAID |