=====================================================
General NPI Number Information
=====================================================
NPI Number | 1194001289
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JANE BISTLINE MD INTERVENTIONAL PAIN, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/02/2011
-----------------------------------------------------
Last Update Date | 12/15/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2031 PALM BEACH LAKES BLVD SUITE 100
-----------------------------------------------------
City | WEST PALM BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33409-6501
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 561-681-9808
-----------------------------------------------------
Fax | 561-681-9989
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2031 PALM BEACH LAKES BLVD SUITE 100
-----------------------------------------------------
City | WEST PALM BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33409-6501
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 561-681-9808
-----------------------------------------------------
Fax | 561-681-9989
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | JANE E BISTLINE
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 561-681-9808
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208VP0014X
-----------------------------------------------------
Taxonomy Name | Interventional Pain Medicine Physician
-----------------------------------------------------
License Number | ME64772
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------