Basic Information
Provider Information | |||||||||
NPI: | 1194134916 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | INTERVENTIONAL SPINE INSTITUTE OF FLORIDA | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | SPINE, ORTHOPEDICS AND REHABILITATION | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 308 S HARBOR CITY BLVD | ||||||||
Address2: | SUITE A | ||||||||
City: | MELBOURNE | ||||||||
State: | FL | ||||||||
PostalCode: | 329011500 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3217330064 | ||||||||
FaxNumber: | 3217337970 | ||||||||
Practice Location | |||||||||
Address1: | 12301 LAKE UNDERHILL RD | ||||||||
Address2: | SUITE 121 | ||||||||
City: | ORLANDO | ||||||||
State: | FL | ||||||||
PostalCode: | 328284508 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3217330064 | ||||||||
FaxNumber: | 3217337970 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/06/2014 | ||||||||
LastUpdateDate: | 05/19/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | DOWDELL | ||||||||
AuthorizedOfficialFirstName: | BRIAN | ||||||||
AuthorizedOfficialMiddleName: | C | ||||||||
AuthorizedOfficialTitleorPosition: | OWNER/CEO/PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 3217330064 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | DR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | M.D. | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208100000X | 60952 | FL | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation |   |
ID Information
ID | Type | State | Issuer | Description | 1326453143 | 01 | FL | NPI-DME-MELBOURNE | OTHER | BD4666965 | 01 | FL | DEA | OTHER | 10708014 | 01 | FL | CAQH | OTHER | ME76009 | 01 | FL | MEDICAL LICENSE | OTHER | K5708 | 01 | FL | MEDICARE GROUP | OTHER | 1225060338 | 01 | FL | NPI GROUP | OTHER | 1639101744 | 01 | FL | NPI INDIVIDUAL | OTHER |