Provider Demographics
NPI:1861783458
Name:ADVANCED INTERVENTIONAL PAIN CLINIC, LLC.
Entity type:Organization
Organization Name:ADVANCED INTERVENTIONAL PAIN CLINIC, LLC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:SWAMY
Authorized Official - Middle Name:
Authorized Official - Last Name:YATHAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:407-622-7246
Mailing Address - Street 1:1170 S SEMORAN BLVD
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32807
Mailing Address - Country:US
Mailing Address - Phone:407-622-7246
Mailing Address - Fax:407-599-7246
Practice Address - Street 1:451 S MILWEE ST
Practice Address - Street 2:
Practice Address - City:LONGWOOD
Practice Address - State:FL
Practice Address - Zip Code:32750-4140
Practice Address - Country:US
Practice Address - Phone:407-622-7246
Practice Address - Fax:407-599-7246
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-29
Last Update Date:2014-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL6523340001Medicare NSC
FLBJ966Medicare PIN