Healthcare Provider Details

I. General information

NPI: 1801169172
Provider Name (Legal Business Name): PIVOTAL HEALTH PHYSICAL MEDICINE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/17/2012
Last Update Date: 07/09/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12479 S ACCESS RD SUITE 1
PORT CHARLOTTE FL
33981-6206
US

IV. Provider business mailing address

12479 S ACCESS RD SUITE 1
PORT CHARLOTTE FL
33981-6206
US

V. Phone/Fax

Practice location:
  • Phone: 941-697-3001
  • Fax: 941-697-6010
Mailing address:
  • Phone: 941-697-3001
  • Fax: 941-697-6010

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberCH8839
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number
License Number State
# 6
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. JEREMIAH B JOSEPH
Title or Position: PRESIDENT
Credential: DC
Phone: 941-473-7900