Provider Demographics
NPI:1457485666
Name:SPINE & SPORTSMEDICINE SPECIALISTS
Entity Type:Organization
Organization Name:SPINE & SPORTSMEDICINE SPECIALISTS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:JEROME
Authorized Official - Last Name:LORD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:904-687-4224
Mailing Address - Street 1:17327 BALLMONT PARK DR
Mailing Address - Street 2:
Mailing Address - City:ODESSA
Mailing Address - State:FL
Mailing Address - Zip Code:33556-6209
Mailing Address - Country:US
Mailing Address - Phone:904-687-4224
Mailing Address - Fax:813-852-2137
Practice Address - Street 1:17327 BALLMONT PARK DR
Practice Address - Street 2:
Practice Address - City:ODESSA
Practice Address - State:FL
Practice Address - Zip Code:33556-6209
Practice Address - Country:US
Practice Address - Phone:904-687-4224
Practice Address - Fax:813-852-2137
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-16
Last Update Date:2012-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty