Provider Demographics
NPI:1215233184
Name:SUNSHINE SPINE AND PAIN PA
Entity type:Organization
Organization Name:SUNSHINE SPINE AND PAIN PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:TERESA
Authorized Official - Middle Name:
Authorized Official - Last Name:FRIEDLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:904-292-2700
Mailing Address - Street 1:PO BOX 919327
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32891-9327
Mailing Address - Country:US
Mailing Address - Phone:904-292-2700
Mailing Address - Fax:904-292-2666
Practice Address - Street 1:14540 OLD SAINT AUGUSTINE RD
Practice Address - Street 2:MOB 2 SUITE 2397
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32258-7418
Practice Address - Country:US
Practice Address - Phone:904-292-2700
Practice Address - Fax:904-292-2666
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-02-09
Last Update Date:2011-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME84002174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL5987360001Medicare NSC
FLG54001Medicare UPIN
FLK8356Medicare PIN