Provider Demographics
NPI:1326478942
Name:NEW TAMPA INTERVENTIONAL PAIN AND SPORTS MEDICINE, INC
Entity Type:Organization
Organization Name:NEW TAMPA INTERVENTIONAL PAIN AND SPORTS MEDICINE, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOSE
Authorized Official - Middle Name:
Authorized Official - Last Name:DE LA TORRE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:813-309-1013
Mailing Address - Street 1:2014 ASHLEY OAKS CIR
Mailing Address - Street 2:SUITE 101
Mailing Address - City:WESLEY CHAPEL
Mailing Address - State:FL
Mailing Address - Zip Code:33544-6400
Mailing Address - Country:US
Mailing Address - Phone:813-999-3030
Mailing Address - Fax:813-991-7377
Practice Address - Street 1:2014 ASHLEY OAKS CIR
Practice Address - Street 2:SUITE 101
Practice Address - City:WESLEY CHAPEL
Practice Address - State:FL
Practice Address - Zip Code:33544-6400
Practice Address - Country:US
Practice Address - Phone:813-999-3030
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-11-18
Last Update Date:2013-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME89848208100000X, 208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty
No208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL269279100Medicaid
FLP00400544OtherRR MEDICARE
FLL12610Medicare UPIN
FLP00400544OtherRR MEDICARE
FL43200X-HILLSBOROUGHMedicare PIN