MEDICARE: ADVANCED PAIN MANAGEMENT CLINIC, INC

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	207LP2900X	Pain Medicine (Anesthesiology) Physician	OS8432	FL

General Provider Information

NPI Number	:	1255565388
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ADVANCED PAIN MANAGEMENT CLINIC, INC

Provider Business Mailing Address
First Line	:	5757 BOOTH RD
Second Line	:	BUILDING 100
City	:	JACKSONVILLE
State	:	FL
Zip	:	32207-5980
Country	:	US
Telephone Number	:	904-683-2596
Fax Number	:	904-683-2597

Provider Business Practice Location Address
First Line	:	5757 BOOTH RD
Second Line	:	BUILDING 100
City	:	JACKSONVILLE
State	:	FL
Zip	:	32207-5980
Country	:	US
Telephone Number	:	904-683-2596
Fax Number	:	904-683-2597

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. MICHAEL SCOTT WILLENS
Credential	:	D.O.
Telephone Number	:	904-635-5555

Provider Enumeration Date	:	05/04/2009
Last Update Date	:	10/01/2012

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