1225060338 NPI number — INTERVENTIONAL SPINE INSTITUTE OF FLORIDA

Table of content: (NPI 1225060338)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1225060338 NPI number — INTERVENTIONAL SPINE INSTITUTE OF FLORIDA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
INTERVENTIONAL SPINE INSTITUTE OF FLORIDA
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1225060338
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/18/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
308 S HARBOR CITY BLVD
Provider Second Line Business Mailing Address:
SUITE A
Provider Business Mailing Address City Name:
MELBOURNE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32901-1500
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
321-733-0064
Provider Business Mailing Address Fax Number:
321-733-7970

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
308 S HARBOR CITY BLVD
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
MELBOURNE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32901-1500
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
321-733-0064
Provider Business Practice Location Address Fax Number:
321-733-7970
Provider Enumeration Date:
07/07/2006

Additional Information

Authorized Official

Authorized Official Last Name:
DOWDELL
Authorized Official First Name:
BRIAN
Authorized Official Middle Name:
CHRISTOPHER
Authorized Official Title or Position:
CEO/MED DIRECTOR
Authorized Official Telephone Number:
321-733-0064

Provider Taxonomy Codes

  • Taxonomy code: 208100000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208VP0014X , with the licence number: ME0076009 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 208VP0014X , with the licence number: ME109841 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)





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