MEDICARE: PAIN MEDICINE INSTITUTE 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	363A00000X	Physician Assistant		FL
2	207LP2900X	Pain Medicine (Anesthesiology) Physician		FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	80785	OTHER	FL	BLUE CROSS BLUE SHIELD

General Provider Information

NPI Number	:	1629020508
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PAIN MEDICINE INSTITUTE PLLC

Provider Business Mailing Address
First Line	:	PO BOX 277999
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30384-7999
Country	:	US
Telephone Number	:	352-867-8898
Fax Number	:	352-732-6282

Provider Business Practice Location Address
First Line	:	6815 14TH ST W
Second Line	:	SUITE 204
City	:	BRADENTON
State	:	FL
Zip	:	34207-5810
Country	:	US
Telephone Number	:	352-867-8898
Fax Number	:	352-732-6282

Authorized Official
Title or Position	:	MD
Name	:	DR. RAYMON PRIEWE
Credential	:	MD
Telephone Number	:	352-867-8898

Provider Enumeration Date	:	05/17/2006
Last Update Date	:	09/15/2011

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