Provider Demographics
NPI:1720073216
Name:PHYSICIAN PROVIDERS GROUP PA
Entity Type:Organization
Organization Name:PHYSICIAN PROVIDERS GROUP PA
Other - Org Name:COMPREHENSIVE PAIN MANAGEMENT CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MD/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:ULSETH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:352-344-4791
Mailing Address - Street 1:PO BOX 1925
Mailing Address - Street 2:
Mailing Address - City:LADY LAKE
Mailing Address - State:FL
Mailing Address - Zip Code:32158-1925
Mailing Address - Country:US
Mailing Address - Phone:523-553-4075
Mailing Address - Fax:888-770-3208
Practice Address - Street 1:305 S LINE AVE
Practice Address - Street 2:
Practice Address - City:INVERNESS
Practice Address - State:FL
Practice Address - Zip Code:34452-4605
Practice Address - Country:US
Practice Address - Phone:352-344-4791
Practice Address - Fax:352-344-3822
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-12
Last Update Date:2023-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL34759OtherBLUE SHIELD PROV #
FL34759OtherBLUE SHIELD PROV #
FL268670800Medicaid
FLDA4473Medicare PIN