Provider Demographics
NPI:1225060338
Name:INTERVENTIONAL SPINE INSTITUTE OF FLORIDA
Entity type:Organization
Organization Name:INTERVENTIONAL SPINE INSTITUTE OF FLORIDA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO/MED DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:CHRISTOPHER
Authorized Official - Last Name:DOWDELL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:321-733-0064
Mailing Address - Street 1:308 S HARBOR CITY BLVD
Mailing Address - Street 2:SUITE A
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32901-1500
Mailing Address - Country:US
Mailing Address - Phone:321-733-0064
Mailing Address - Fax:321-733-7970
Practice Address - Street 1:308 S HARBOR CITY BLVD
Practice Address - Street 2:SUITE A
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32901-1500
Practice Address - Country:US
Practice Address - Phone:321-733-0064
Practice Address - Fax:321-733-7970
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-07
Last Update Date:2012-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
208100000X
FLME0076009208VP0014X
FLME109841208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain MedicineGroup - Multi-Specialty
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL5637640001Medicare NSC
FLDB323Medicare PIN