Healthcare Provider Details

I. General information

NPI: 1528508090
Provider Name (Legal Business Name): BLUE WATER PAIN SOLUTIONS, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/03/2017
Last Update Date: 03/03/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2 OAKWOOD BLVD SUITE 195
HOLLYWOOD FL
33020-1960
US

IV. Provider business mailing address

PO BOX 277597
MIRAMAR FL
33027-7597
US

V. Phone/Fax

Practice location:
  • Phone: 954-447-5206
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: ROBERT J COWARD
Title or Position: PRESIDENT
Credential:
Phone: 954-838-2371