Healthcare Provider Details

I. General information

NPI: 1194001289
Provider Name (Legal Business Name): JANE BISTLINE MD INTERVENTIONAL PAIN, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/02/2011
Last Update Date: 12/15/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2031 PALM BEACH LAKES BLVD SUITE 100
WEST PALM BEACH FL
33409-6501
US

IV. Provider business mailing address

2031 PALM BEACH LAKES BLVD SUITE 100
WEST PALM BEACH FL
33409-6501
US

V. Phone/Fax

Practice location:
  • Phone: 561-681-9808
  • Fax: 561-681-9989
Mailing address:
  • Phone: 561-681-9808
  • Fax: 561-681-9989

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License NumberME64772
License Number StateFL

VIII. Authorized Official

Name: JANE E BISTLINE
Title or Position: PRESIDENT
Credential: M.D.
Phone: 561-681-9808