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General NPI Number Information
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NPI Number | 1336682764
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Entity Type | Organization
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Legal Business Name | PALM TREE INTERVENTIONAL PAIN MANAGEMENT, PLLC
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Dates
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Enumeration Date | 12/03/2016
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Last Update Date | 10/01/2020
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Provider Practice Location Address
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Address Line | 2801 17TH ST UNIT 202
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City | SAINT CLOUD
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State | FL
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Zip | 34769-4939
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Country | US
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Telephone | 407-906-1328
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Fax | 866-425-8143
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Provider Business Mailing Address
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Address Line | 2801 17TH ST UNIT 202
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City | SAINT CLOUD
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State | FL
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Zip | 34769-4939
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Country | US
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Telephone | 407-906-1328
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Fax | 866-425-8143
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Authorized Official
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Title or Position | MEDICAL DIRECTOR
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Name | JASON JEONG HWAN SONG
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Credential | MD
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Telephone | 267-312-9857
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208100000X
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Taxonomy Name | Physical Medicine & Rehabilitation Physician
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License Number |
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License Number State | FL
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Taxonomy #2
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Taxonomy Code | 208VP0014X
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Taxonomy Name | Interventional Pain Medicine Physician
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License Number |
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License Number State | FL
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Taxonomy #3
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Taxonomy Code | 2081P2900X
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Taxonomy Name | Pain Medicine (Physical Medicine & Rehabilitation) Physician
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License Number |
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License Number State |
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