Basic Information
Provider Information | |||||||||
NPI: | 1154549905 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | FLORIDA PAIN & REHABILITATION INSTITUTE INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | FLORIDA PAIN AND REHABILITATION CENTER | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
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: | 918 ROLLING ACRES RD STE 102 | ||||||||
Address2: |   | ||||||||
City: | LADY LAKE | ||||||||
State: | FL | ||||||||
PostalCode: | 321595027 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3527516582 | ||||||||
FaxNumber: | 8663307528 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/24/2007 | ||||||||
LastUpdateDate: | 07/06/2017 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | SAJAN | ||||||||
AuthorizedOfficialFirstName: | CHERIAN | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
AuthorizedOfficialTelephone: | 4076225766 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | FLORIDA PAIN AND REHABILITATION ASSOCIATES INC | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | MD | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208VP0014X | ME109651 | FL | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pain Medicine | Interventional Pain Medicine |
ID Information
ID | Type | State | Issuer | Description | 4273890017 | 01 | FL | MEDICARE DME PROVIDER ID | OTHER |