| Entity Name: | INTEGRA NEURO PAIN INSTITUTE PA |
| Jurisdiction: | FLORIDA |
| Filing Type: | Domestic Profit |
| Status: | Active |
| Date Filed: | 15 Nov 2018 (6 years ago) |
| Document Number: | P18000094508 |
| FEI/EIN Number | 83-2582180 |
| Address: | 8297 CHAMPIONS GATE BLVD, 463, CHAMPIONS GATE, FL, 33896, FL |
| Mail Address: | 8297 CHAMPIONS GATE BLVD, 463, CHAMPIONS GATE, FL, 33896, FL |
| ZIP code: | 33896 |
| County: | Polk |
| Place of Formation: | FLORIDA |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1881158939 | 2019-01-23 | 2023-04-17 | 8297 CHAMPIONS GATE BLVD STE 463, CHAMPIONS GATE, FL, 338968387, US | 5979 VINELAND RD STE 114, ORLANDO, FL, 328197855, US | |||||||||||||||||||||||||
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| Phone | +1 863-547-0788 |
| Fax | 8635470789 |
Authorized person
| Name | DR. MOHAMMAD MASOOM QURESHI |
| Role | PRESIDENT/PHYSICIAN |
| Phone | 8635470788 |
Taxonomy
| Taxonomy Code | 2084N0400X - Neurology Physician |
| Is Primary | Yes |
| Taxonomy Code | 2084P2900X - Pain Medicine (Psychiatry & Neurology) Physician |
| Is Primary | No |
Other Provider Identifiers
| Issuer | MEDICAID |
| Number | 021662900 |
| State | FL |
| Name | Role | Address |
|---|---|---|
| QURESHI MOHAMMAD | Agent | 8297 CHAMPIONS GATE BLVD, CHAMPIONS GATE, FL, 33896 |
| Name | Role | Address |
|---|---|---|
| QURESHI MOHAMMAD | President | 8297 CHAMPIONS GATE BLVD #463, CHAMPIONS GATE, FL, 33896 |
| Name | Role | Address |
|---|---|---|
| AWAN AMAL | Vice President | 8297 CHAMPIONS GATE BLVD, CHAMPIONS GATE, FL, 33896 |
| Name | Role | Address |
|---|---|---|
| Mayes Tonya | Prac | 8297 CHAMPIONS GATE BLVD, CHAMPIONS GATE, FL, 33896 |
| Name | Date |
|---|---|
| ANNUAL REPORT | 2024-02-06 |
| ANNUAL REPORT | 2023-01-18 |
| ANNUAL REPORT | 2022-02-21 |
| AMENDED ANNUAL REPORT | 2021-05-05 |
| ANNUAL REPORT | 2021-03-15 |
| ANNUAL REPORT | 2020-01-20 |
| ANNUAL REPORT | 2019-05-01 |
| Domestic Profit | 2018-11-15 |
Date of last update: 02 Feb 2025
Sources: Florida Department of State
