1588073308 NPI number — INTERVENTIONAL SPINE INSTITUTE OF FLORIDA, PA

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1588073308 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:
1588073308
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:
40 ALEXANDRIA BLVD
Provider Second Line Business Practice Location Address:
SUITE 1030
Provider Business Practice Location Address City Name:
OVIEDO
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32765-3300
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: 332B00000X , with the licence number:  60952 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • 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" .

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

  • Identifier: 10708014 . This is a "CAQH" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: K5708 . This is a "MEDICARE GROUP" 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: 1225060338 . This is a "NPI GROUP" 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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