Provider Demographics
NPI:1942363395
Name:SPACE COAST NEUROLOGY AND PAIN MANAGEMENT PA
Entity Type:Organization
Organization Name:SPACE COAST NEUROLOGY AND PAIN MANAGEMENT PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MASOOD
Authorized Official - Middle Name:
Authorized Official - Last Name:HASHMI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:321-984-7997
Mailing Address - Street 1:4951 BABCOCK ST NE
Mailing Address - Street 2:SUITE 1
Mailing Address - City:PALM BAY
Mailing Address - State:FL
Mailing Address - Zip Code:32905-2821
Mailing Address - Country:US
Mailing Address - Phone:321-984-7997
Mailing Address - Fax:321-984-7935
Practice Address - Street 1:4951 BABCOCK ST NE
Practice Address - Street 2:SUITE 1
Practice Address - City:PALM BAY
Practice Address - State:FL
Practice Address - Zip Code:32905-2821
Practice Address - Country:US
Practice Address - Phone:321-984-7997
Practice Address - Fax:321-984-7935
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-18
Last Update Date:2008-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0072245174400000X
FLARNP 9203833174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL269085300Medicaid
FLK5569Medicare PIN