Provider Demographics
NPI:1841242823
Name:CHARLES S. THEOFILOS MD PA
Entity Type:Organization
Organization Name:CHARLES S. THEOFILOS MD PA
Other - Org Name:THE SPINE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHYSICIAN OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:S
Authorized Official - Last Name:THEOFILOS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:561-630-3870
Mailing Address - Street 1:300 VILLAGE SQUARE XING STE 202
Mailing Address - Street 2:
Mailing Address - City:PALM BEACH GARDENS
Mailing Address - State:FL
Mailing Address - Zip Code:33410-3223
Mailing Address - Country:US
Mailing Address - Phone:561-630-3870
Mailing Address - Fax:561-630-3680
Practice Address - Street 1:300 VILLAGE SQUARE XING STE 202
Practice Address - Street 2:
Practice Address - City:PALM BEACH GARDENS
Practice Address - State:FL
Practice Address - Zip Code:33410-3223
Practice Address - Country:US
Practice Address - Phone:561-630-3870
Practice Address - Fax:561-630-3680
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-17
Last Update Date:2021-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLXXXXXXXXXXXXXXXX207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL23144OtherINDIVIDUAL MEDICARE NUMBE
FL373280100Medicaid
FLK0574Medicare ID - Type Unspecified
FL23144OtherINDIVIDUAL MEDICARE NUMBE