Healthcare Provider Details

I. General information

NPI: 1659214625
Provider Name (Legal Business Name): ORLANDO PAIN MANAGEMENT CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/13/2026
Last Update Date: 04/16/2026
Certification Date: 04/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5425 S SEMORAN BLVD STE 11
ORLANDO FL
32822-1777
US

IV. Provider business mailing address

5425 S SEMORAN BLVD STE 11
ORLANDO FL
32822-1777
US

V. Phone/Fax

Practice location:
  • Phone: 407-658-4616
  • Fax: 407-658-4617
Mailing address:
  • Phone: 407-658-4616
  • Fax: 407-658-4617

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: PHAEDRA LUND SHUDRA
Title or Position: CREDENTIALING AND CONTRACTING SPEC
Credential:
Phone: 813-785-4861