Provider Demographics
NPI:1538453618
Name:PELVIC PAIN DIAGNOSTIC AND TREATMENT CENTER
Entity type:Organization
Organization Name:PELVIC PAIN DIAGNOSTIC AND TREATMENT CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE PROPRIETOR/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GERARD
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:DILEO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:985-373-7517
Mailing Address - Street 1:1918 ROBINHOOD ST
Mailing Address - Street 2:
Mailing Address - City:SARASOTA
Mailing Address - State:FL
Mailing Address - Zip Code:34231-3620
Mailing Address - Country:US
Mailing Address - Phone:985-630-0498
Mailing Address - Fax:941-538-9415
Practice Address - Street 1:1918 ROBINHOOD ST
Practice Address - Street 2:
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34231-3620
Practice Address - Country:US
Practice Address - Phone:985-630-0498
Practice Address - Fax:941-538-9415
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-06-06
Last Update Date:2011-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME95062207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL275476200Medicaid
FL10982309OtherCAQH
FL10982309OtherCAQH