=====================================================
General NPI Number Information
=====================================================
NPI Number | 1235227075
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | INSTITUTE OF INTERVENTIONAL PAIN MANAGEMENT PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/10/2006
-----------------------------------------------------
Last Update Date | 12/29/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11319 CORTEZ BLVD
-----------------------------------------------------
City | BROOKSVILLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34613-5407
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 352-597-0907
-----------------------------------------------------
Fax | 352-597-2243
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 5719
-----------------------------------------------------
City | SPRING HILL
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34611-5719
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 352-597-0907
-----------------------------------------------------
Fax | 352-597-2243
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. DEBORAH H TRACY
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 352-597-0907
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208VP0014X
-----------------------------------------------------
Taxonomy Name | Interventional Pain Medicine Physician
-----------------------------------------------------
License Number | 276400470
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------