Provider Demographics
NPI:1780350298
Name:SPINE INSTITUTE ON THE EMERALD COAST
Entity type:Organization
Organization Name:SPINE INSTITUTE ON THE EMERALD COAST
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHIEF MEDICAL OFFICER; OWNER
Authorized Official - Prefix:
Authorized Official - First Name:AMRISH
Authorized Official - Middle Name:
Authorized Official - Last Name:PATEL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:850-460-2350
Mailing Address - Street 1:PO BOX 600366
Mailing Address - Street 2:
Mailing Address - City:ST JOHNS
Mailing Address - State:FL
Mailing Address - Zip Code:32260-0366
Mailing Address - Country:US
Mailing Address - Phone:904-717-9625
Mailing Address - Fax:904-683-6499
Practice Address - Street 1:12276 SAN JOSE BLVD STE 210
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32223-8631
Practice Address - Country:US
Practice Address - Phone:904-717-9625
Practice Address - Fax:904-683-6499
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-08-17
Last Update Date:2024-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain MedicineGroup - Multi-Specialty
No208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain MedicineGroup - Multi-Specialty