Basic Information
| Provider Information | |||||||||
| NPI: | 1225060338 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | INTERVENTIONAL SPINE INSTITUTE OF FLORIDA | ||||||||
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| OtherOrganizationName: | BREVARD REHABILITATION MEDICINE | ||||||||
| OtherOrganizationType: | 4 | ||||||||
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| 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: | 308 S HARBOR CITY BLVD | ||||||||
| Address2: | SUITE A | ||||||||
| City: | MELBOURNE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 329011500 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3217330064 | ||||||||
| FaxNumber: | 3217337970 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/07/2006 | ||||||||
| LastUpdateDate: | 07/18/2012 | ||||||||
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| AuthorizedOfficialLastName: | DOWDELL | ||||||||
| AuthorizedOfficialFirstName: | BRIAN | ||||||||
| AuthorizedOfficialMiddleName: | CHRISTOPHER | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO/MED DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 3217330064 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208100000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | 208VP0014X | ME109841 | FL | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pain Medicine | Interventional Pain Medicine | 208VP0014X | ME0076009 | FL | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pain Medicine | Interventional Pain Medicine |
No ID Information.