=====================================================
General NPI Number Information
=====================================================
NPI Number | 1134571128
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TAMPA INSTITUTE FOR PAIN AND SPINE, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/01/2016
-----------------------------------------------------
Last Update Date | 07/31/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 13140 ELK MOUNTAIN DR SUITE B
-----------------------------------------------------
City | RIVERVIEW
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33579
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 813-513-8477
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 13140 ELK MOUNTAIN DR SUITE B
-----------------------------------------------------
City | RIVERVIEW
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33579-7182
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 813-513-8477
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | JESSEN MUKALEL
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 813-513-8477
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207LP2900X
-----------------------------------------------------
Taxonomy Name | Pain Medicine (Anesthesiology) Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 2084N0400X
-----------------------------------------------------
Taxonomy Name | Neurology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 208VP0000X
-----------------------------------------------------
Taxonomy Name | Pain Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 208VP0014X
-----------------------------------------------------
Taxonomy Name | Interventional Pain Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------