Provider Demographics
NPI:1306211743
Name:SAINT PETERSBURG INTERVENTIONAL PAIN MANAGEMENT LLC
Entity Type:Organization
Organization Name:SAINT PETERSBURG INTERVENTIONAL PAIN MANAGEMENT LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:
Authorized Official - First Name:DANYA
Authorized Official - Middle Name:ALIDA
Authorized Official - Last Name:GODOY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:172-714-8573
Mailing Address - Street 1:620 10TH ST NORTH
Mailing Address - Street 2:2D
Mailing Address - City:SAINT PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33704
Mailing Address - Country:US
Mailing Address - Phone:727-824-8383
Mailing Address - Fax:
Practice Address - Street 1:620 10TH ST N
Practice Address - Street 2:SUITE 2D
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33705-1407
Practice Address - Country:US
Practice Address - Phone:727-824-8383
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-12-10
Last Update Date:2015-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME85040208VP0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL269485900Medicaid
43250QMedicare PIN
FL269485900Medicaid