Provider Demographics
NPI:1326101270
Name:ANDALUSIA PAIN, REHAB & SPORTS MEDICINE
Entity Type:Organization
Organization Name:ANDALUSIA PAIN, REHAB & SPORTS MEDICINE
Other - Org Name:EMERALD COAST SPINE SPORTS MEDICINE & REHAB
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MD PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JAIME
Authorized Official - Middle Name:ARTURO
Authorized Official - Last Name:FOLAND
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:850-654-4041
Mailing Address - Street 1:PO BOX 6855
Mailing Address - Street 2:
Mailing Address - City:MIRAMAR BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32550-1015
Mailing Address - Country:US
Mailing Address - Phone:850-654-4041
Mailing Address - Fax:850-654-5339
Practice Address - Street 1:12671 US HIGHWAY 98 W
Practice Address - Street 2:FOUNTAIN PLAZA SUITE 215
Practice Address - City:SANDESTIN
Practice Address - State:FL
Practice Address - Zip Code:32550-8300
Practice Address - Country:US
Practice Address - Phone:850-654-4041
Practice Address - Fax:850-654-5339
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-19
Last Update Date:2007-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME891382081P2900X, 2081S0010X
AL256632081P2900X, 2081S0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain MedicineGroup - Multi-Specialty
No2081S0010XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationSports MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLK9773Medicare PIN
ALJ958Medicare PIN