Provider Demographics
NPI:1235227075
Name:INSTITUTE OF INTERVENTIONAL PAIN MANAGEMENT PA
Entity Type:Organization
Organization Name:INSTITUTE OF INTERVENTIONAL PAIN MANAGEMENT PA
Other - Org Name:WEST FLORIDA ANESTHESIA
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DEBORAH
Authorized Official - Middle Name:H
Authorized Official - Last Name:TRACY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:352-597-0907
Mailing Address - Street 1:PO BOX 5719
Mailing Address - Street 2:
Mailing Address - City:SPRING HILL
Mailing Address - State:FL
Mailing Address - Zip Code:34611-5719
Mailing Address - Country:US
Mailing Address - Phone:352-597-0907
Mailing Address - Fax:352-597-2243
Practice Address - Street 1:11319 CORTEZ BLVD
Practice Address - Street 2:
Practice Address - City:BROOKSVILLE
Practice Address - State:FL
Practice Address - Zip Code:34613-5407
Practice Address - Country:US
Practice Address - Phone:352-597-0907
Practice Address - Fax:352-597-2243
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-10
Last Update Date:2009-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL276400470208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
5301427OtherGHI
CA4235OtherRRMC
07882OtherBLUE CROSS/BLUE SHIELD
FL377097400Medicaid
07882WMedicare PIN
E21436Medicare UPIN
5301427OtherGHI