Provider Demographics
NPI:1205864121
Name:INTERVENTIONAL PAIN MANAGEMENT OF THE TREASURE COAST PA
Entity Type:Organization
Organization Name:INTERVENTIONAL PAIN MANAGEMENT OF THE TREASURE COAST PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:D
Authorized Official - Last Name:ZIMMERMAN
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:772-778-2444
Mailing Address - Street 1:3745 11TH CIRCLE
Mailing Address - Street 2:SUITE 107
Mailing Address - City:VERO BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32960
Mailing Address - Country:US
Mailing Address - Phone:772-778-2444
Mailing Address - Fax:772-778-8299
Practice Address - Street 1:3745 11TH CIRCLE
Practice Address - Street 2:SUITE 107
Practice Address - City:VERO BEACH
Practice Address - State:FL
Practice Address - Zip Code:32960
Practice Address - Country:US
Practice Address - Phone:772-778-2444
Practice Address - Fax:772-778-8299
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-29
Last Update Date:2009-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS0007702208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLE23975Medicare UPIN
FLK8857Medicare ID - Type UnspecifiedGROUP#