MEDICARE: FLORIDA INSTITUTE OF PAIN MEDICINE LLC

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy
1	208VP0014X	Interventional Pain Medicine Physician
2	225100000X	Physical Therapist
3	261QP3300X	Pain Clinic/Center
4	207LP2900X	Pain Medicine (Anesthesiology) Physician

General Provider Information

NPI Number	:	1740750967
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FLORIDA INSTITUTE OF PAIN MEDICINE LLC

Provider Business Mailing Address
First Line	:	PO BOX 734905
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75373-4905
Country	:	US
Telephone Number	:	904-449-7246
Fax Number	:	904-719-7571

Provider Business Practice Location Address
First Line	:	206 ASHOURIAN AVE STE 206
Second Line	:
City	:	ST AUGUSTINE
State	:	FL
Zip	:	32092-5107
Country	:	US
Telephone Number	:	904-449-7246
Fax Number	:	904-719-7571

Authorized Official
Title or Position	:	OWNER
Name	:	JERRY R FOLTZ
Credential	:	MD
Telephone Number	:	904-449-7246

Provider Enumeration Date	:	11/30/2018
Last Update Date	:	08/20/2021

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Directions to “FLORIDA INSTITUTE OF PAIN MEDICINE LLC ” Practice Location

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