Provider Demographics
NPI:1013383835
Name:45TH ST PAIN MANAGEMENT LLC
Entity Type:Organization
Organization Name:45TH ST PAIN MANAGEMENT LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:GARDY
Authorized Official - Middle Name:D
Authorized Official - Last Name:MARCELIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:561-469-2635
Mailing Address - Street 1:5642 CORPORATE WAY
Mailing Address - Street 2:
Mailing Address - City:WEST PALM BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33407-2002
Mailing Address - Country:US
Mailing Address - Phone:561-469-2635
Mailing Address - Fax:561-469-2614
Practice Address - Street 1:5642 CORPORATE WAY
Practice Address - Street 2:
Practice Address - City:WEST PALM BEACH
Practice Address - State:FL
Practice Address - Zip Code:33407-2002
Practice Address - Country:US
Practice Address - Phone:561-469-2635
Practice Address - Fax:561-469-2614
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-08-16
Last Update Date:2015-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME97529208100000X, 208VP0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty
No208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLME76415Medicare PIN