Provider Demographics
NPI:1336651009
Name:JACKSONVILLE BRAIN & SPINE PLLC
Entity Type:Organization
Organization Name:JACKSONVILLE BRAIN & SPINE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:J
Authorized Official - Last Name:PETR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:513-284-6634
Mailing Address - Street 1:7807 BAYMEADOWS RD E STE 208
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32256-9666
Mailing Address - Country:US
Mailing Address - Phone:904-330-0302
Mailing Address - Fax:904-330-0418
Practice Address - Street 1:7807 BAYMEADOWS RD E STE 208
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32256-9666
Practice Address - Country:US
Practice Address - Phone:904-446-9991
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-11-02
Last Update Date:2018-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological SurgeryGroup - Single Specialty