Basic Information
| Provider Information | |||||||||
| NPI: | 1588073308 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | INTERVENTIONAL SPINE INSTITUTE OF FLORIDA, PA | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | SPINE, ORTHOPEDICS AND REHABILITATION | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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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: | 40 ALEXANDRIA BLVD | ||||||||
| Address2: | SUITE 1030 | ||||||||
| City: | OVIEDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 327653300 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3217330064 | ||||||||
| FaxNumber: | 3217337970 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/06/2014 | ||||||||
| LastUpdateDate: | 10/02/2014 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| 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 | 332B00000X | 60952 | FL | N | Suppliers | Durable Medical Equipment & Medical Supplies | 174400000X | 60952 | FL | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | BD4666965 | 01 | FL | DEA | OTHER | 10708014 | 01 | FL | CAQH | OTHER | K5708 | 01 | FL | MEDICARE GROUP | OTHER | ME76009 | 01 | FL | MEDICAL LICENSE | OTHER | 1225060338 | 01 | FL | NPI GROUP | OTHER | 1326453143 | 01 | FL | NPI-DME-MELBOURNE | OTHER | 1639101744 | 01 | FL | NPI INDIVIDUAL | OTHER |