MEDICARE: BLUE WATER PAIN SOLUTIONS, PA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207LP2900X	Pain Medicine (Anesthesiology) Physician

General Provider Information

NPI Number	:	1033513494
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BLUE WATER PAIN SOLUTIONS, PA

Provider Business Mailing Address
First Line	:	PO BOX 277597
Second Line	:
City	:	MIRAMAR
State	:	FL
Zip	:	33027-7597
Country	:	US
Telephone Number	:	800-437-2672
Fax Number	:

Provider Business Practice Location Address
First Line	:	3000 BAYVIEW DR
Second Line	:
City	:	FORT LAUDERDALE
State	:	FL
Zip	:	33306-1772
Country	:	US
Telephone Number	:	954-447-5206
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. LOWELL S. DAVIS
Credential	:
Telephone Number	:	954-447-5206

Provider Enumeration Date	:	10/14/2014
Last Update Date	:	10/14/2014

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