Provider Demographics
NPI:1861470049
Name:ADVANCED PAIN CLINIC PA
Entity Type:Organization
Organization Name:ADVANCED PAIN CLINIC PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:VRAJLAL
Authorized Official - Middle Name:L
Authorized Official - Last Name:RAJYAGURU
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:407-935-9404
Mailing Address - Street 1:505 W VINE ST
Mailing Address - Street 2:SUITE # 301
Mailing Address - City:KISSIMMEE
Mailing Address - State:FL
Mailing Address - Zip Code:34741-4156
Mailing Address - Country:US
Mailing Address - Phone:407-935-9404
Mailing Address - Fax:407-935-9304
Practice Address - Street 1:505 W VINE ST
Practice Address - Street 2:SUITE 301
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34741-4156
Practice Address - Country:US
Practice Address - Phone:407-935-9404
Practice Address - Fax:407-935-9304
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-06
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0066759207L00000X, 207LP2900X
FL261QP3300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain MedicineGroup - Single Specialty
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty
No261QP3300XAmbulatory Health Care FacilitiesClinic/CenterPainGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL377046000Medicaid
F96484Medicare UPIN
FL377046000Medicaid
26492AMedicare ID - Type Unspecified
FL26492BMedicare ID - Type Unspecified