MEDICARE: INTEGRA NEURO PAIN INSTITUTE PA

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	2084P2900X	Pain Medicine (Psychiatry & Neurology) Physician
2	2084N0400X	Neurology Physician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1881158939
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	INTEGRA NEURO PAIN INSTITUTE PA

Provider Business Mailing Address
First Line	:	8297 CHAMPIONS GATE BLVD STE 463
Second Line	:
City	:	CHAMPIONS GATE
State	:	FL
Zip	:	33896-8387
Country	:	US
Telephone Number	:	863-547-0788
Fax Number	:	863-547-0789

Provider Business Practice Location Address
First Line	:	212 S DIXIE DR
Second Line	:
City	:	HAINES CITY
State	:	FL
Zip	:	33844-2801
Country	:	US
Telephone Number	:	863-547-0788
Fax Number	:	863-547-0789

Authorized Official
Title or Position	:	PRESIDENT/PHYSICIAN
Name	:	DR. MOHAMMAD MASOOM QURESHI
Credential	:	MD
Telephone Number	:	863-547-0788

Provider Enumeration Date	:	01/23/2019
Last Update Date	:	06/04/2026

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