MEDICARE: PIVOTAL HEALTH PHYSICAL MEDICINE, 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
2	111N00000X	Chiropractor	CH8839	FL
3	363A00000X	Physician Assistant
4	332B00000X	Durable Medical Equipment & Medical Supplies
5	363LA2200X	Adult Health Nurse Practitioner
6	207R00000X	Internal Medicine Physician

General Provider Information

NPI Number	:	1801169172
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PIVOTAL HEALTH PHYSICAL MEDICINE, LLC

Provider Business Mailing Address
First Line	:	12479 S ACCESS RD
Second Line	:	SUITE 1
City	:	PORT CHARLOTTE
State	:	FL
Zip	:	33981-6206
Country	:	US
Telephone Number	:	941-697-3001
Fax Number	:	941-697-6010

Provider Business Practice Location Address
First Line	:	12479 S ACCESS RD
Second Line	:	SUITE 1
City	:	PORT CHARLOTTE
State	:	FL
Zip	:	33981-6206
Country	:	US
Telephone Number	:	941-697-3001
Fax Number	:	941-697-6010

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. JEREMIAH B JOSEPH
Credential	:	DC
Telephone Number	:	941-473-7900

Provider Enumeration Date	:	02/17/2012
Last Update Date	:	07/09/2014

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