Provider Demographics
NPI:1891078861
Name:PAIN TREATMENT CENTER OF FLORIDA, INC
Entity type:Organization
Organization Name:PAIN TREATMENT CENTER OF FLORIDA, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:GENERAL PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:S
Authorized Official - Last Name:SIDHOM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:813-731-0416
Mailing Address - Street 1:PO BOX 1005
Mailing Address - Street 2:
Mailing Address - City:LUTZ
Mailing Address - State:FL
Mailing Address - Zip Code:33548-1005
Mailing Address - Country:US
Mailing Address - Phone:813-731-0416
Mailing Address - Fax:
Practice Address - Street 1:4106 HENDERSON BLVD
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33629-5750
Practice Address - Country:US
Practice Address - Phone:813-731-0416
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-09-26
Last Update Date:2011-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPENDINGMedicare PIN