Provider Demographics
NPI:1336682764
Name:PALM TREE INTERVENTIONAL PAIN MANAGEMENT, PLLC
Entity Type:Organization
Organization Name:PALM TREE INTERVENTIONAL PAIN MANAGEMENT, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JASON
Authorized Official - Middle Name:JEONG HWAN
Authorized Official - Last Name:SONG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:267-312-9857
Mailing Address - Street 1:2801 17TH ST UNIT 202
Mailing Address - Street 2:
Mailing Address - City:SAINT CLOUD
Mailing Address - State:FL
Mailing Address - Zip Code:34769-4939
Mailing Address - Country:US
Mailing Address - Phone:407-906-1328
Mailing Address - Fax:866-425-8143
Practice Address - Street 1:2801 17TH ST UNIT 202
Practice Address - Street 2:
Practice Address - City:SAINT CLOUD
Practice Address - State:FL
Practice Address - Zip Code:34769-4939
Practice Address - Country:US
Practice Address - Phone:407-906-1328
Practice Address - Fax:866-425-8143
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-12-03
Last Update Date:2020-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL208100000X, 208VP0014X
2081P2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain MedicineGroup - Single Specialty
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty
No208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL020119900Medicaid