MEDICARE: FLA PAIN MANAGEMENT, LLC

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	208VP0000X	Pain Medicine Physician	OS1683	FL

General Provider Information

NPI Number	:	1053631382
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FLA PAIN MANAGEMENT, LLC

Provider Business Mailing Address
First Line	:	279 DOUGLAS AVE
Second Line	:	SUITE 1108
City	:	ALTAMONTE SPRINGS
State	:	FL
Zip	:	32714-3324
Country	:	US
Telephone Number	:	407-622-7640
Fax Number	:	407-622-7644

Provider Business Practice Location Address
First Line	:	279 DOUGLAS AVE
Second Line	:	SUITE 1108
City	:	ALTAMONTE SPRINGS
State	:	FL
Zip	:	32714-3324
Country	:	US
Telephone Number	:	407-622-7640
Fax Number	:	407-622-7644

Authorized Official
Title or Position	:	PHYSICIAN
Name	:	MR. BODO PYKO
Credential	:	D.O.
Telephone Number	:	407-622-7640

Provider Enumeration Date	:	06/09/2010
Last Update Date	:	06/09/2010

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