Provider Demographics
NPI:1972770428
Name:ADVANCED PAIN CLINIC PA
Entity Type:Organization
Organization Name:ADVANCED PAIN CLINIC PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
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 2:301
Mailing Address - City:KISSIMMEE
Mailing Address - State:FL
Mailing Address - Zip Code:34741-4123
Mailing Address - Country:US
Mailing Address - Phone:407-935-9404
Mailing Address - Fax:
Practice Address - Street 1:82 MAXCY PLAZA CIR
Practice Address - Street 2:
Practice Address - City:HAINES CITY
Practice Address - State:FL
Practice Address - Zip Code:33844-2488
Practice Address - Country:US
Practice Address - Phone:407-935-9404
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-14
Last Update Date:2008-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0066759207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL377046000Medicaid
FL26492BMedicare PIN