NPIMap

Organization Active NPI

Palm Tree Interventional Pain Management, PLLC

  • Pain Medicine (Physical Medicine & Rehabilitation) Physician
  • Saint Cloud, FL
National Provider Identifier
1336682764
Registry record updated Oct 1, 2020
On this page

Key facts

NPPES NPI Registry
Primary specialty
Pain Medicine (Physical Medicine & Rehabilitation) PhysicianTaxonomy code 2081P2900X
Legal business name
PALM TREE INTERVENTIONAL PAIN MANAGEMENT, PLLC
Practice address
2801 17TH St Unit 202
Saint Cloud, FL 34769-4939
Phone
(407) 906-1328
Fax
(866) 425-8143
NPI assigned
Dec 3, 2016
Last updated
Oct 1, 2020By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Oct 1, 2020

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Jason Jeong Hwan Song, MDNPI 1205074002
Title
Medical Director
Phone
(267) 312-9857

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 3

Specialty (taxonomy)CodeLicenseStatePrimary
Physical Medicine & Rehabilitation Physician 208100000X FL
Pain Medicine (Physical Medicine & Rehabilitation) Physician 2081P2900X Primary
Interventional Pain Medicine Physician 208VP0014X FL

Addresses

Primary practice location

2801 17TH St Unit 202
Saint Cloud, FL 34769-4939

Mailing address

2801 17TH St Unit 202
Saint Cloud, FL 34769-4939
Phone (407) 906-1328

Other identifiers 1

IdentifierTypeStateIssuer
020119900MedicaidFL

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in FL2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20180118001391 FL Part B Supplier - Clinic/Group Practice 2062771173 Receives reassigned benefits from 3 practitioners
Practice locations: Kissimmee, FL; Saint Cloud, FL
O20180809004555 FL DME Supplier - Physician - Unknown Physician Specialty 2062771173 Practice locations: Saint Cloud, FL

National Provider Directory

National Provider Directory

Locations

2029 Hickory Tree Rd
Saint Cloud, FL 34772
Phone (321) 805-4850

Practitioners & affiliated clinicians

Practitioners 13

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

View all 13

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1480723200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1601510400000",
    "number": "1336682764",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "2801 17TH ST UNIT 202",
            "city": "SAINT CLOUD",
            "state": "FL",
            "postal_code": "347694939",
            "telephone_number": "407-906-1328",
            "fax_number": "866-425-8143"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "2801 17TH ST UNIT 202",
            "city": "SAINT CLOUD",
            "state": "FL",
            "postal_code": "347694939",
            "telephone_number": "407-906-1328",
            "fax_number": "866-425-8143"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "PALM TREE INTERVENTIONAL PAIN MANAGEMENT, PLLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2016-12-03",
        "last_updated": "2020-10-01",
        "certification_date": "2020-10-01",
        "status": "A",
        "authorized_official_last_name": "SONG",
        "authorized_official_first_name": "JASON",
        "authorized_official_middle_name": "JEONG HWAN",
        "authorized_official_title_or_position": "MEDICAL DIRECTOR",
        "authorized_official_telephone_number": "267-312-9857",
        "authorized_official_credential": "MD"
    },
    "taxonomies": [
        {
            "code": "208100000X",
            "taxonomy_group": "",
            "desc": "Physical Medicine & Rehabilitation",
            "state": "FL",
            "license": null,
            "primary": false
        },
        {
            "code": "2081P2900X",
            "taxonomy_group": "",
            "desc": "Physical Medicine & Rehabilitation, Pain Medicine",
            "state": null,
            "license": null,
            "primary": true
        },
        {
            "code": "208VP0014X",
            "taxonomy_group": "",
            "desc": "Pain Medicine, Interventional Pain Medicine",
            "state": "FL",
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "020119900",
            "state": "FL"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Saint Cloud, FL

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Oct 1, 2020; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.