Basic Information
Provider Information | |||||||||
NPI: | 1144383746 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | OUCH, PA | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | PHYSICIANS PAIN CENTER | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 105 SOUTHPARK BLVD | ||||||||
Address2: | SUITE C 300 | ||||||||
City: | ST AUGUSTINE | ||||||||
State: | FL | ||||||||
PostalCode: | 320864162 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9048087246 | ||||||||
FaxNumber: | 9048087090 | ||||||||
Practice Location | |||||||||
Address1: | 105 SOUTHPARK BLVD | ||||||||
Address2: | SUITE C 300 | ||||||||
City: | ST AUGUSTINE | ||||||||
State: | FL | ||||||||
PostalCode: | 320864162 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9048087246 | ||||||||
FaxNumber: | 9048087090 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/18/2006 | ||||||||
LastUpdateDate: | 11/17/2011 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | PATEL | ||||||||
AuthorizedOfficialFirstName: | JYOTI | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | PARTNER | ||||||||
AuthorizedOfficialTelephone: | 9048087246 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | DR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | MD | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X |   |   | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |   |
ID Information
ID | Type | State | Issuer | Description | 7612385 | 01 | FL | AETNA | OTHER | 34189 | 01 | FL | BLUE CROSS BLUE SHIELD | OTHER |