MEDICARE: PREMIER PAIN MANAGEMENT, PLLC

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	208VP0014X	Interventional Pain Medicine Physician	ME100973	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1164422705	OTHER	FL	NPI

General Provider Information

NPI Number	:	1043606387
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PREMIER PAIN MANAGEMENT, PLLC

Provider Business Mailing Address
First Line	:	PO BOX 9161
Second Line	:
City	:	CORAL SPRINGS
State	:	FL
Zip	:	33075-9161
Country	:	US
Telephone Number	:	973-698-7768
Fax Number	:

Provider Business Practice Location Address
First Line	:	3255 NW 94TH AVE
Second Line	:	SUITE 9161
City	:	CORAL SPRINGS
State	:	FL
Zip	:	33075-2001
Country	:	US
Telephone Number	:	973-698-7768
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT/PHYSICIAN
Name	:	JANICE DEBRA VICTOR
Credential	:	M.D.
Telephone Number	:	973-698-7768

Provider Enumeration Date	:	04/14/2015
Last Update Date	:	04/14/2015

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