MEDICARE: SPINE SPECIALISTS OF AMERICA LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207XS0117X	Orthopaedic Surgery of the Spine Physician	ME54499	FL
2	208VP0014X	Interventional Pain Medicine Physician	ME115987	FL
3	208VP0014X	Interventional Pain Medicine Physician	ME85743	FL

General Provider Information

NPI Number	:	1881022903
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SPINE SPECIALISTS OF AMERICA LLC

Provider Business Mailing Address
First Line	:	13035 W LINEBAUGH AVE STE 101F
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33626-4481
Country	:	US
Telephone Number	:	727-474-9729
Fax Number	:	727-474-9947

Provider Business Practice Location Address
First Line	:	13035 W LINEBAUGH AVE STE 101F
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33626-4481
Country	:	US
Telephone Number	:	727-474-9729
Fax Number	:	727-474-9947

Authorized Official
Title or Position	:	MEMBER
Name	:	ERIC K GROTEKE
Credential	:	DC
Telephone Number	:	727-474-9729

Provider Enumeration Date	:	10/29/2013
Last Update Date	:	10/29/2013

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