Basic Information
| Provider Information | |||||||||
| NPI: | 1942252531 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MARTIN COUNTY PAIN CLINIC PL | ||||||||
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| Mailing Information | |||||||||
| Address1: | 725 SE OSCEOLA ST STE 2 | ||||||||
| Address2: | |||||||||
| City: | STUART | ||||||||
| State: | FL | ||||||||
| PostalCode: | 349942318 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7722860078 | ||||||||
| FaxNumber: | 7722862288 | ||||||||
| Practice Location | |||||||||
| Address1: | 725 SE OSCEOLA ST | ||||||||
| Address2: | SUITE 2 | ||||||||
| City: | STUART | ||||||||
| State: | FL | ||||||||
| PostalCode: | 349942318 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7722860078 | ||||||||
| FaxNumber: | 8666652702 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/16/2006 | ||||||||
| LastUpdateDate: | 05/06/2019 | ||||||||
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| AuthorizedOfficialLastName: | GARDNER | ||||||||
| AuthorizedOfficialFirstName: | ALBERT | ||||||||
| AuthorizedOfficialMiddleName: | E | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7722860078 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208VP0000X | N | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pain Medicine | Pain Medicine | 332900000X | ME15899 | FL | Y | Suppliers | Non-Pharmacy Dispensing Site |
ID Information
| ID | Type | State | Issuer | Description | 274837100 | 05 | FL | MEDICAID | 39289 | 01 | FL | BCBS FL GROUP # | OTHER |