Provider Demographics
NPI:1902071418
Name:WEST FLORIDA PAIN MANAGEMENT PA
Entity type:Organization
Organization Name:WEST FLORIDA PAIN MANAGEMENT PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:G
Authorized Official - Last Name:MONTGOMERY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:727-553-7330
Mailing Address - Street 1:603 7TH STREET SOUTH
Mailing Address - Street 2:SUITE 340
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33701-4732
Mailing Address - Country:US
Mailing Address - Phone:727-553-7313
Mailing Address - Fax:727-553-7320
Practice Address - Street 1:1831 N BELCHER RD
Practice Address - Street 2:A-2
Practice Address - City:CLEARWATER
Practice Address - State:FL
Practice Address - Zip Code:33765-1449
Practice Address - Country:US
Practice Address - Phone:727-553-7313
Practice Address - Fax:727-553-7320
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-25
Last Update Date:2008-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME52154174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL257607400Medicaid
FL257607400Medicaid