Provider Demographics
NPI:1689852493
Name:SPORTS & INTERVENTIONAL PAIN MEDICINE
Entity Type:Organization
Organization Name:SPORTS & INTERVENTIONAL PAIN MEDICINE
Other - Org Name:SIPM
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE
Authorized Official - Prefix:DR
Authorized Official - First Name:EATON
Authorized Official - Middle Name:I
Authorized Official - Last Name:YEN
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:727-359-2552
Mailing Address - Street 1:PO BOX 340287
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33694-0287
Mailing Address - Country:US
Mailing Address - Phone:727-359-2552
Mailing Address - Fax:727-372-0402
Practice Address - Street 1:8140 PICTON WAY
Practice Address - Street 2:SUITE 101
Practice Address - City:TRINITY
Practice Address - State:FL
Practice Address - Zip Code:34655-1792
Practice Address - Country:US
Practice Address - Phone:727-359-2552
Practice Address - Fax:727-372-0402
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-04
Last Update Date:2011-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS92632081P2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLBS675AMedicare PIN