Basic Information
Provider Information | |||||||||
NPI: | 1942241575 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | LEVINE | ||||||||
FirstName: | MARC | ||||||||
MiddleName: | IVEN | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 3500 SW CENTER CT | ||||||||
Address2: |   | ||||||||
City: | PALM CITY | ||||||||
State: | FL | ||||||||
PostalCode: | 349902312 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 1772222115 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 111 SE OSCEOLA ST STE 100 | ||||||||
Address2: |   | ||||||||
City: | STUART | ||||||||
State: | FL | ||||||||
PostalCode: | 349942114 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7722232115 | ||||||||
FaxNumber: | 7722239238 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/08/2006 | ||||||||
LastUpdateDate: | 12/22/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 12/22/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207LP2900X | ME56758 | FL | Y |   | Allopathic & Osteopathic Physicians | Anesthesiology | Pain Medicine | 208VP0014X | ME56758 | FL | N |   | Allopathic & Osteopathic Physicians | Pain Medicine | Interventional Pain Medicine |
ID Information
ID | Type | State | Issuer | Description | 17953 | 01 |   | BCBS | OTHER |