Provider Demographics
NPI:1245802727
Name:INSTITUTE FOR HEALTH SPORTS SPINE REHABILITATION & PAIN MANAGEMENT
Entity Type:Organization
Organization Name:INSTITUTE FOR HEALTH SPORTS SPINE REHABILITATION & PAIN MANAGEMENT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP OF OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:SHANNON
Authorized Official - Middle Name:
Authorized Official - Last Name:RILEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:904-647-5266
Mailing Address - Street 1:111 MARGARET ST
Mailing Address - Street 2:
Mailing Address - City:SAINT MARYS
Mailing Address - State:GA
Mailing Address - Zip Code:31558-4930
Mailing Address - Country:US
Mailing Address - Phone:904-647-5266
Mailing Address - Fax:904-770-5594
Practice Address - Street 1:4100 SOUTHPOINT DR E STE 1
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32216-8710
Practice Address - Country:US
Practice Address - Phone:904-647-5266
Practice Address - Fax:904-770-5594
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:INSTITUTE FOR HEALTH SPORTS SPINE REHABILITATION & PAIN MANAGEMENT
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2021-07-14
Last Update Date:2021-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL014945000Medicaid