Provider Demographics
NPI:1689681793
Name:INTERVENTIONAL PAIN SERVICE LLC
Entity Type:Organization
Organization Name:INTERVENTIONAL PAIN SERVICE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:ROSS
Authorized Official - Last Name:MAYFIELD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:386-254-4029
Mailing Address - Street 1:201 N CLYDE MORRIS BLVD
Mailing Address - Street 2:SUITE 120
Mailing Address - City:DAYTONA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32114-2724
Mailing Address - Country:US
Mailing Address - Phone:386-254-4029
Mailing Address - Fax:386-254-4274
Practice Address - Street 1:201 N CLYDE MORRIS BLVD
Practice Address - Street 2:SUITE 120
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32114-2724
Practice Address - Country:US
Practice Address - Phone:386-254-4029
Practice Address - Fax:386-254-4274
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0063660208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL372693200Medicaid
FL18828OtherBLUE SHIELD
FLD99666Medicare UPIN