Provider Demographics
NPI:1457306441
Name:PAIN MANAGEMENT OF BREVARD PLC
Entity Type:Organization
Organization Name:PAIN MANAGEMENT OF BREVARD PLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT OF PMB
Authorized Official - Prefix:
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:
Authorized Official - Last Name:BLOOM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:407-667-0444
Mailing Address - Street 1:291 SOUTHHALL LN
Mailing Address - Street 2:
Mailing Address - City:MAITLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32751-7290
Mailing Address - Country:US
Mailing Address - Phone:407-667-0444
Mailing Address - Fax:407-667-4338
Practice Address - Street 1:110 LONGWOOD AVE
Practice Address - Street 2:
Practice Address - City:ROCKLEDGE
Practice Address - State:FL
Practice Address - Zip Code:32955-2828
Practice Address - Country:US
Practice Address - Phone:407-667-0444
Practice Address - Fax:407-667-4338
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-24
Last Update Date:2012-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain MedicineGroup - Multi-Specialty
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL259812400Medicaid
FL45472OtherBCBS
FLK1906Medicare ID - Type Unspecified