MEDICARE: 45TH ST PAIN MANAGEMENT LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208VP0000X	Pain Medicine Physician	ME97529	FL
2	208100000X	Physical Medicine & Rehabilitation Physician	ME97529	FL

General Provider Information

NPI Number	:	1013383835
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	45TH ST PAIN MANAGEMENT LLC

Provider Business Mailing Address
First Line	:	5642 CORPORATE WAY
Second Line	:
City	:	WEST PALM BEACH
State	:	FL
Zip	:	33407-2002
Country	:	US
Telephone Number	:	561-469-2635
Fax Number	:	561-469-2614

Provider Business Practice Location Address
First Line	:	5642 CORPORATE WAY
Second Line	:
City	:	WEST PALM BEACH
State	:	FL
Zip	:	33407-2002
Country	:	US
Telephone Number	:	561-469-2635
Fax Number	:	561-469-2614

Authorized Official
Title or Position	:	CEO
Name	:	DR. GARDY D MARCELIN
Credential	:	MD
Telephone Number	:	561-469-2635

Provider Enumeration Date	:	08/16/2015
Last Update Date	:	08/16/2015

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Directions to “45TH ST PAIN MANAGEMENT LLC ” Practice Location

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