Provider Demographics
NPI:1942252531
Name:MARTIN COUNTY PAIN CLINIC PL
Entity Type:Organization
Organization Name:MARTIN COUNTY PAIN CLINIC PL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ALBERT
Authorized Official - Middle Name:E
Authorized Official - Last Name:GARDNER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:772-286-0078
Mailing Address - Street 1:725 SE OSCEOLA ST STE 2
Mailing Address - Street 2:
Mailing Address - City:STUART
Mailing Address - State:FL
Mailing Address - Zip Code:34994-2318
Mailing Address - Country:US
Mailing Address - Phone:772-286-0078
Mailing Address - Fax:772-286-2288
Practice Address - Street 1:725 SE OSCEOLA ST
Practice Address - Street 2:SUITE 2
Practice Address - City:STUART
Practice Address - State:FL
Practice Address - Zip Code:34994-2318
Practice Address - Country:US
Practice Address - Phone:772-286-0078
Practice Address - Fax:866-665-2702
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-16
Last Update Date:2019-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
208VP0000X
FLME15899332900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes332900000XSuppliersNon-Pharmacy Dispensing SiteGroup - Single Specialty
No208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL274837100Medicaid
FL39289OtherBCBS FL GROUP #
FLK9035Medicare ID - Type UnspecifiedMEDICARE GROUP NUMBER