Provider Demographics
NPI:1700843513
Name:SOUTHEASTERN INTERVENTIONAL PAIN PHYSICIANS, P.A.
Entity Type:Organization
Organization Name:SOUTHEASTERN INTERVENTIONAL PAIN PHYSICIANS, P.A.
Other - Org Name:EMERALD COAST PAIN PHYSICIANS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEDICAL BILLER
Authorized Official - Prefix:
Authorized Official - First Name:PATRICIA
Authorized Official - Middle Name:
Authorized Official - Last Name:NEWSOM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:850-243-7788
Mailing Address - Street 1:PO BOX 699
Mailing Address - Street 2:
Mailing Address - City:GULF BREEZE
Mailing Address - State:FL
Mailing Address - Zip Code:32562-0699
Mailing Address - Country:US
Mailing Address - Phone:850-243-7788
Mailing Address - Fax:850-243-7738
Practice Address - Street 1:151 MARY ESTHER BLVD
Practice Address - Street 2:SUITE 303
Practice Address - City:MARY ESTHER
Practice Address - State:FL
Practice Address - Zip Code:32569-1972
Practice Address - Country:US
Practice Address - Phone:850-243-7788
Practice Address - Fax:850-243-7738
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-26
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL45117OtherBLUE CROSS BLUE SHIELD
FL45117OtherBLUE CROSS BLUE SHIELD