Basic Information
| Provider Information | |||||||||
| NPI: | 1538311345 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SPINECARE ANESTHESIA LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5700 MIDNIGHT PASS RD | ||||||||
| Address2: | SUITE 4 | ||||||||
| City: | SARASOTA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 342423083 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8883373509 | ||||||||
| FaxNumber: | 9413283997 | ||||||||
| Practice Location | |||||||||
| Address1: | 1564 KINGSLEY AVE | ||||||||
| Address2: | |||||||||
| City: | ORANGE PARK | ||||||||
| State: | FL | ||||||||
| PostalCode: | 320734511 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9042640400 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/13/2008 | ||||||||
| LastUpdateDate: | 02/07/2011 | ||||||||
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| AuthorizedOfficialLastName: | NOBACK | ||||||||
| AuthorizedOfficialFirstName: | CARL | ||||||||
| AuthorizedOfficialMiddleName: | R | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9413601566 | ||||||||
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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 | 208VP0000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pain Medicine | Pain Medicine |
ID Information
| ID | Type | State | Issuer | Description | 98887 | 01 | FL | BCBSFL | OTHER |