1396154118 NPI number — INTERVENTIONAL SPINE INSTITUTE OF FLORIDA, PA

Table of content: (NPI 1396154118)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1396154118 NPI number — INTERVENTIONAL SPINE INSTITUTE OF FLORIDA, PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
INTERVENTIONAL SPINE INSTITUTE OF FLORIDA, PA
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:
1396154118
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/07/2023
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:
1315 S INTERNATIONAL PKWY
Provider Second Line Business Practice Location Address:
SUITE 1111
Provider Business Practice Location Address City Name:
LAKE MARY
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32746-1407
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:
08/06/2014

Additional Information

Authorized Official

Authorized Official Last Name:
DOWDELL
Authorized Official First Name:
BRIAN
Authorized Official Middle Name:
C
Authorized Official Title or Position:
OWNER/CEO/PRESIDENT
Authorized Official Telephone Number:
321-733-0064

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  60952 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 332B00000X , with the licence number: 60952 , 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)

  • Identifier: K5708 . This is a "MEDICARE GROUP" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 1225060338 . This is a "NPI GROUP" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 10708014 . This is a "CAQH" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: ME76009 . This is a "MEDICAL LICENSE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 1326453143 . This is a "NPI-DME-MELBOURNE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 1639101744 . This is a "NPI INDIVIDUAL" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".




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