Healthcare Provider Details

I. General information

NPI: 1346710571
Provider Name (Legal Business Name): FLORIDA INSTITUTE OF PAIN MEDICINE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/30/2018
Last Update Date: 08/20/2021
Certification Date: 08/20/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

105 WHITEHALL DR STE 115
ST AUGUSTINE FL
32086-5269
US

IV. Provider business mailing address

PO BOX 734905
DALLAS TX
75373-4905
US

V. Phone/Fax

Practice location:
  • Phone: 904-800-7246
  • Fax: 904-299-4116
Mailing address:
  • Phone: 904-449-7246
  • Fax: 904-719-7571

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number
License Number State

VIII. Authorized Official

Name: JERRY R FOLTZ
Title or Position: OWNER
Credential: MD
Phone: 904-449-7246