Basic Information
| Provider Information | |||||||||
| NPI: | 1801169172 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PIVOTAL HEALTH PHYSICAL MEDICINE, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 12479 S ACCESS RD | ||||||||
| Address2: | SUITE 1 | ||||||||
| City: | PORT CHARLOTTE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 339816206 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9416973001 | ||||||||
| FaxNumber: | 9416976010 | ||||||||
| Practice Location | |||||||||
| Address1: | 12479 S ACCESS RD | ||||||||
| Address2: | SUITE 1 | ||||||||
| City: | PORT CHARLOTTE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 339816206 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9416973001 | ||||||||
| FaxNumber: | 9416976010 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/17/2012 | ||||||||
| LastUpdateDate: | 07/09/2014 | ||||||||
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| AuthorizedOfficialLastName: | JOSEPH | ||||||||
| AuthorizedOfficialFirstName: | JEREMIAH | ||||||||
| AuthorizedOfficialMiddleName: | B | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9414737900 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | DC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208VP0000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pain Medicine | Pain Medicine | 111N00000X | CH8839 | FL | N | 193200000X MULTI-SPECIALTY GROUP | Chiropractic Providers | Chiropractor | 363A00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 332B00000X | N | Suppliers | Durable Medical Equipment & Medical Supplies | 363LA2200X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health | 207R00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.