Provider Demographics
NPI:1821218488
Name:CENTER FOR SPINE MEDICINE PA
Entity Type:Organization
Organization Name:CENTER FOR SPINE MEDICINE PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:GRUDEM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:352-629-7011
Mailing Address - Street 1:3200 SW 34TH AVE
Mailing Address - Street 2:SUITE 502
Mailing Address - City:OCALA
Mailing Address - State:FL
Mailing Address - Zip Code:34474-7456
Mailing Address - Country:US
Mailing Address - Phone:352-629-7011
Mailing Address - Fax:352-629-7924
Practice Address - Street 1:3200 SW 34TH AVE
Practice Address - Street 2:SUITE 502
Practice Address - City:OCALA
Practice Address - State:FL
Practice Address - Zip Code:34474-7456
Practice Address - Country:US
Practice Address - Phone:352-629-7011
Practice Address - Fax:352-629-7924
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-26
Last Update Date:2008-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME 61060208VP0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL94747OtherBCBS GROUP
FLK3309Medicare ID - Type UnspecifiedMEDICARE GROUP