Basic Information
| Provider Information | |||||||||
| NPI: | 1801245626 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FLORIDA PAIN & REHABILITATION INSTITUTE INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | INTERVENTIONAL MEDICAL ASSOCIATES | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5365 W ATLANTIC AVE STE 504 | ||||||||
| Address2: | |||||||||
| City: | DELRAY BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 334848194 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5612419300 | ||||||||
| FaxNumber: | 5612419339 | ||||||||
| Practice Location | |||||||||
| Address1: | 6821 NW 11TH PL | ||||||||
| Address2: | |||||||||
| City: | GAINESVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 326054216 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3523313353 | ||||||||
| FaxNumber: | 3523339035 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/13/2016 | ||||||||
| LastUpdateDate: | 12/14/2018 | ||||||||
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| AuthorizedOfficialLastName: | SAJAN | ||||||||
| AuthorizedOfficialFirstName: | CHERIAN | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 4076225766 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | FLORIDA PAIN AND REHABILITATION ASSOCIATES INC | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2081P2900X | ME109651 | FL | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | Pain Medicine | 208VP0000X | ME109651 | FL | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pain Medicine | Pain Medicine | 208VP0014X | ME109651 | FL | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pain Medicine | Interventional Pain Medicine |
ID Information
| ID | Type | State | Issuer | Description | 4273890019 | 01 | FL | MEDICARE NSC | OTHER |