Provider Demographics
NPI:1356396774
Name:MICROSPINE PHYSICIANS GROUP LLC
Entity type:Organization
Organization Name:MICROSPINE PHYSICIANS GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:ANGEL
Authorized Official - Middle Name:D
Authorized Official - Last Name:BARBER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:850-892-6001
Mailing Address - Street 1:101 MICROSPINE WAY
Mailing Address - Street 2:
Mailing Address - City:DEFUNIAK SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:32435-6323
Mailing Address - Country:US
Mailing Address - Phone:850-892-6001
Mailing Address - Fax:850-892-4212
Practice Address - Street 1:101 MICROSPINE WAY
Practice Address - Street 2:
Practice Address - City:DEFUNIAK SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:32435-6323
Practice Address - Country:US
Practice Address - Phone:850-892-6001
Practice Address - Fax:850-892-4212
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MICROSPINE INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-05-24
Last Update Date:2007-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RS0010XAllopathic & Osteopathic PhysiciansInternal MedicineSports MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL34912OtherBCBS PROVIDER (NONPAR) NU
FL34912OtherBCBS PROVIDER (NONPAR) NU