Provider Demographics
NPI:1801169172
Name:PIVOTAL HEALTH PHYSICAL MEDICINE, LLC
Entity type:Organization
Organization Name:PIVOTAL HEALTH PHYSICAL MEDICINE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JEREMIAH
Authorized Official - Middle Name:B
Authorized Official - Last Name:JOSEPH
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:941-473-7900
Mailing Address - Street 1:12479 S ACCESS RD
Mailing Address - Street 2:SUITE 1
Mailing Address - City:PORT CHARLOTTE
Mailing Address - State:FL
Mailing Address - Zip Code:33981-6206
Mailing Address - Country:US
Mailing Address - Phone:941-697-3001
Mailing Address - Fax:941-697-6010
Practice Address - Street 1:12479 S ACCESS RD
Practice Address - Street 2:SUITE 1
Practice Address - City:PORT CHARLOTTE
Practice Address - State:FL
Practice Address - Zip Code:33981-6206
Practice Address - Country:US
Practice Address - Phone:941-697-3001
Practice Address - Fax:941-697-6010
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-17
Last Update Date:2014-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
208VP0000X, 363A00000X, 332B00000X, 363LA2200X, 207R00000X
FLCH8839111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain MedicineGroup - Multi-Specialty
No111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Multi-Specialty
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL6681410001Medicare NSC
FLGN035AMedicare PIN