Healthcare Provider Details

I. General information

NPI: 1629436910
Provider Name (Legal Business Name): PHYSICAL MEDICINE AND PAIN CONSULTANTS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/02/2016
Last Update Date: 10/01/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1790 E VENICE AVE STE 102
VENICE FL
34292-3191
US

IV. Provider business mailing address

614 RAVENNA ST
VENICE FL
34285-3028
US

V. Phone/Fax

Practice location:
  • Phone: 941-488-0074
  • Fax: 941-488-2074
Mailing address:
  • Phone: 941-488-0074
  • Fax: 941-488-2074

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number
License Number State

VIII. Authorized Official

Name: DAVID HABER
Title or Position: OWNER
Credential: DP
Phone: 941-488-0074