Provider Demographics
NPI:1104166735
Name:BRAIN AND SPINE INSTATE FOR CHILDREN
Entity type:Organization
Organization Name:BRAIN AND SPINE INSTATE FOR CHILDREN
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:KEYNE
Authorized Official - Middle Name:K
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:407-378-5100
Mailing Address - Street 1:2813 S HIAWASSEE RD
Mailing Address - Street 2:SUITE 201
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32835-6300
Mailing Address - Country:US
Mailing Address - Phone:407-378-5100
Mailing Address - Fax:
Practice Address - Street 1:2813 S HIAWASSEE RD
Practice Address - Street 2:SUITE 201
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32835-6300
Practice Address - Country:US
Practice Address - Phone:407-378-5100
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-02-19
Last Update Date:2013-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME 102412305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL000384900Medicaid