Healthcare Provider Details

I. General information

NPI: 1629020508
Provider Name (Legal Business Name): PAIN MEDICINE INSTITUTE PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/17/2006
Last Update Date: 09/15/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6815 14TH ST W SUITE 204
BRADENTON FL
34207-5810
US

IV. Provider business mailing address

PO BOX 277999
ATLANTA GA
30384-7999
US

V. Phone/Fax

Practice location:
  • Phone: 352-867-8898
  • Fax: 352-732-6282
Mailing address:
  • Phone: 352-867-8898
  • Fax: 352-732-6282

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number StateFL

VIII. Authorized Official

Name: DR. RAYMON PRIEWE
Title or Position: MD
Credential: MD
Phone: 352-867-8898