Provider Demographics
NPI:1316179245
Name:ADVANCED PAIN MANAGEMENT CLINIC, LLC
Entity Type:Organization
Organization Name:ADVANCED PAIN MANAGEMENT CLINIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:S
Authorized Official - Last Name:WILLENS
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:904-635-5555
Mailing Address - Street 1:5757 BOOTH ROAD
Mailing Address - Street 2:BLDG 100
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32207
Mailing Address - Country:US
Mailing Address - Phone:904-683-2596
Mailing Address - Fax:904-683-2597
Practice Address - Street 1:5757 BOOTH ROAD
Practice Address - Street 2:BLDG 100
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32207
Practice Address - Country:US
Practice Address - Phone:904-683-2596
Practice Address - Fax:904-683-2597
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-08-11
Last Update Date:2010-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS8432207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLH46915Medicare UPIN