Provider Demographics
NPI:1396072765
Name:THE SPINE INSTITUTE AT ORTHOPAEDIC ASSOCIATES PL
Entity type:Organization
Organization Name:THE SPINE INSTITUTE AT ORTHOPAEDIC ASSOCIATES PL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:KORNELIS
Authorized Official - Middle Name:A
Authorized Official - Last Name:POELSTRA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:850-797-6027
Mailing Address - Street 1:1034 MAR WALT DR
Mailing Address - Street 2:SUITE 310
Mailing Address - City:FORT WALTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32547-6645
Mailing Address - Country:US
Mailing Address - Phone:850-797-6027
Mailing Address - Fax:850-797-6027
Practice Address - Street 1:1034 MAR WALT DR
Practice Address - Street 2:SUITE 310
Practice Address - City:FORT WALTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:32547-6645
Practice Address - Country:US
Practice Address - Phone:850-797-6027
Practice Address - Fax:850-797-6027
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-11-05
Last Update Date:2012-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLAPPLIEDMedicare PIN
FLAPPLIEDMedicare UPIN