Provider Demographics
NPI:1962767913
Name:DREAM MEDICAL LLC
Entity type:Organization
Organization Name:DREAM MEDICAL LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:AARON
Authorized Official - Middle Name:J
Authorized Official - Last Name:SHORES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:850-763-8000
Mailing Address - Street 1:2103 JENKS AVE
Mailing Address - Street 2:
Mailing Address - City:PANAMA CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32405-4511
Mailing Address - Country:US
Mailing Address - Phone:850-763-8000
Mailing Address - Fax:850-785-1122
Practice Address - Street 1:877 3RD ST
Practice Address - Street 2:SUITE 3
Practice Address - City:CHIPLEY
Practice Address - State:FL
Practice Address - Zip Code:32428-1827
Practice Address - Country:US
Practice Address - Phone:850-638-0505
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-05
Last Update Date:2012-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME89523208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL6598520001Medicare NSC