Healthcare Provider Details

I. General information

NPI: 1780935700
Provider Name (Legal Business Name): ST. JOSEPH PAIN & ANESTHESIA CONSULTANTS, P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/01/2012
Last Update Date: 10/01/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1804 WIND RIDGE CT
FLEMING ISLAND FL
32003-4704
US

IV. Provider business mailing address

1804 WIND RIDGE CT
FLEMING ISLAND FL
32003-4704
US

V. Phone/Fax

Practice location:
  • Phone: 904-647-9199
  • Fax:
Mailing address:
  • Phone: 904-647-9199
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number
License Number State

VIII. Authorized Official

Name: REYNALDO PARDO
Title or Position: PRESIDENT/TREASURER
Credential: M.D.
Phone: 904-647-9199