=====================================================
General NPI Number Information
=====================================================
NPI Number | 1225244395
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PAIN CLINIC OF NORTHWEST FL, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/15/2007
-----------------------------------------------------
Last Update Date | 01/03/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4284 KELSON AVE
-----------------------------------------------------
City | MARIANNA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32446
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 850-784-2477
-----------------------------------------------------
Fax | 850-784-6848
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2250 HARRISON AVE
-----------------------------------------------------
City | PANAMA CITY
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32405
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 850-784-2477
-----------------------------------------------------
Fax | 850-784-6848
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. ROBERT J JOSEPH
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 850-784-2477
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------