Provider Demographics
NPI:1811967250
Name:FLORIDA PAIN MANAGEMENT CENTER, INC
Entity type:Organization
Organization Name:FLORIDA PAIN MANAGEMENT CENTER, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:STACY
Authorized Official - Middle Name:J
Authorized Official - Last Name:BERCKES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:352-735-3313
Mailing Address - Street 1:111 WATERMAN AVE
Mailing Address - Street 2:
Mailing Address - City:MOUNT DORA
Mailing Address - State:FL
Mailing Address - Zip Code:32757-9541
Mailing Address - Country:US
Mailing Address - Phone:352-735-3313
Mailing Address - Fax:352-735-3711
Practice Address - Street 1:111 WATERMAN AVE
Practice Address - Street 2:
Practice Address - City:MOUNT DORA
Practice Address - State:FL
Practice Address - Zip Code:32757-9541
Practice Address - Country:US
Practice Address - Phone:352-735-3313
Practice Address - Fax:352-735-3711
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-26
Last Update Date:2013-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain MedicineGroup - Multi-Specialty
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Multi-Specialty
No208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain MedicineGroup - Multi-Specialty
No208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL0053506100Medicaid
FL0053506100Medicaid