Provider Demographics
NPI:1639364912
Name:SOUTH PALM ORTHOSPINE INSTITUTE
Entity Type:Organization
Organization Name:SOUTH PALM ORTHOSPINE INSTITUTE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:STEWART
Authorized Official - Middle Name:
Authorized Official - Last Name:EIDELSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:561-742-5959
Mailing Address - Street 1:6110 W ATLANTIC AVE
Mailing Address - Street 2:UNIT A
Mailing Address - City:DELRAY BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33484-8405
Mailing Address - Country:US
Mailing Address - Phone:561-742-5959
Mailing Address - Fax:561-732-0553
Practice Address - Street 1:2900 N MILITARY TRL
Practice Address - Street 2:#241
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33431-6365
Practice Address - Country:US
Practice Address - Phone:561-742-5959
Practice Address - Fax:561-732-0553
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SOUTH PALM ORTHOSPINE INSTITUTE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-09-11
Last Update Date:2007-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME55593207XS0117X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207XS0117XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Surgery of the SpineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AD477Medicare PIN