Healthcare Provider Details

I. General information

NPI: 1013383835
Provider Name (Legal Business Name): 45TH ST PAIN MANAGEMENT LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/16/2015
Last Update Date: 08/16/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5642 CORPORATE WAY
WEST PALM BEACH FL
33407-2002
US

IV. Provider business mailing address

5642 CORPORATE WAY
WEST PALM BEACH FL
33407-2002
US

V. Phone/Fax

Practice location:
  • Phone: 561-469-2635
  • Fax: 561-469-2614
Mailing address:
  • Phone: 561-469-2635
  • Fax: 561-469-2614

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License NumberME97529
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License NumberME97529
License Number StateFL

VIII. Authorized Official

Name: DR. GARDY D MARCELIN
Title or Position: CEO
Credential: MD
Phone: 561-469-2635