Provider Demographics
NPI:1205012325
Name:PHYSIATRIC PAIN & MEDICAL REHABILITATION CLINIC PA
Entity Type:Organization
Organization Name:PHYSIATRIC PAIN & MEDICAL REHABILITATION CLINIC PA
Other - Org Name:NONE
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:NNAMDI
Authorized Official - Middle Name:
Authorized Official - Last Name:NWAOGWUGWU
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:407-291-3077
Mailing Address - Street 1:882 SOUTH KIRKMAN ROAD, STE 305
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32811
Mailing Address - Country:US
Mailing Address - Phone:407-291-3077
Mailing Address - Fax:
Practice Address - Street 1:882 S KIRKMAN RD STE 305
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32811-2652
Practice Address - Country:US
Practice Address - Phone:407-291-3077
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-18
Last Update Date:2011-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME767352081P2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain MedicineGroup - Single Specialty