Basic Information
| Provider Information | |||||||||
| NPI: | 1144649823 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | FLORIDA PAIN & REHABILITATION INSTITUTE INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | ADVANCED INTERVENTIONAL PAIN CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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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: | 1170 S SEMORAN BLVD | ||||||||
| Address2: | |||||||||
| City: | ORLANDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 328071458 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4076227246 | ||||||||
| FaxNumber: | 4075997246 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/10/2014 | ||||||||
| LastUpdateDate: | 08/08/2016 | ||||||||
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| AuthorizedOfficialLastName: | SAJAN | ||||||||
| AuthorizedOfficialFirstName: | CHERIAN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 4076225766 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | FLORIDA PAIN & REHABILITATION ASSOC INC | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208VP0000X | ME98251 | FL | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pain Medicine | Pain Medicine | 2081P2900X | ME98251 | FL | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | Pain Medicine | 208VP0014X | ME98251 | FL | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pain Medicine | Interventional Pain Medicine |
ID Information
| ID | Type | State | Issuer | Description | 014953700 | 05 | FL | MEDICAID |