Provider Demographics
NPI:1942603899
Name:PAIN MEDICINE PHYSICIANS OF JACKSONVILLE, LLC
Entity Type:Organization
Organization Name:PAIN MEDICINE PHYSICIANS OF JACKSONVILLE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:PARVEEN
Authorized Official - Middle Name:
Authorized Official - Last Name:KHANNA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:904-495-7200
Mailing Address - Street 1:10250 NORMANDY BLVD
Mailing Address - Street 2:SUITE 703
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32221-8059
Mailing Address - Country:US
Mailing Address - Phone:904-495-7200
Mailing Address - Fax:904-495-7199
Practice Address - Street 1:10250 NORMANDY BOULEVARD
Practice Address - Street 2:SUITE 702
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32221
Practice Address - Country:US
Practice Address - Phone:904-495-7200
Practice Address - Fax:904-495-7199
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-07
Last Update Date:2017-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME87424207L00000X, 207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain MedicineGroup - Multi-Specialty
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL007Z4OtherBLUECROSSBLUESHIELD
FLDV2304OtherMEDICARE RR
FLDV2304OtherMEDICARE RR