Provider Demographics
NPI:1396526901
Name:INTERVENTIONAL SPINE AND PAIN INSTITUTE LLC
Entity type:Organization
Organization Name:INTERVENTIONAL SPINE AND PAIN INSTITUTE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING AND CONTRACTING SPECI
Authorized Official - Prefix:
Authorized Official - First Name:PHAEDRA
Authorized Official - Middle Name:LUND
Authorized Official - Last Name:SHUDRA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:813-785-4861
Mailing Address - Street 1:777 37TH ST STE C101
Mailing Address - Street 2:
Mailing Address - City:VERO BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32960-7301
Mailing Address - Country:US
Mailing Address - Phone:772-360-1997
Mailing Address - Fax:772-492-3541
Practice Address - Street 1:5200 BABCOCK ST NE STE 111
Practice Address - Street 2:
Practice Address - City:PALM BAY
Practice Address - State:FL
Practice Address - Zip Code:32905-4639
Practice Address - Country:US
Practice Address - Phone:772-360-1997
Practice Address - Fax:772-492-3541
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-10-10
Last Update Date:2024-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain MedicineGroup - Multi-Specialty
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Multi-Specialty
No207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain MedicineGroup - Multi-Specialty
No207RH0002XAllopathic & Osteopathic PhysiciansInternal MedicineHospice and Palliative MedicineGroup - Multi-Specialty
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty
No208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain MedicineGroup - Multi-Specialty