Healthcare Provider Details

I. General information

NPI: 1780865618
Provider Name (Legal Business Name): TAMPA PAIN RELIEF CENTER, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/20/2007
Last Update Date: 05/06/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3000 MEDICAL PARK DR STE 510
TAMPA FL
33613-6602
US

IV. Provider business mailing address

4919 MEMORIAL HWY STE 200
TAMPA FL
33634-7500
US

V. Phone/Fax

Practice location:
  • Phone: 813-569-6500
  • Fax:
Mailing address:
  • Phone: 813-569-6500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2081P2900X
TaxonomyPain Medicine (Physical Medicine & Rehabilitation) Physician
License Number
License Number State

VIII. Authorized Official

Name: JENNIFER BOYD BALDOCK
Title or Position: OFFICER AND AUTHORIZED OFFICIAL
Credential:
Phone: 615-234-5900