MEDICARE: JACKSONVILLE SPINE CENTER PA

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	208VP0014X	Interventional Pain Medicine Physician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1992444624
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JACKSONVILLE SPINE CENTER PA

Provider Business Mailing Address
First Line	:	5191 FIRST COAST TECH PKWY
Second Line	:	3RD FLOOR
City	:	JACKSONVILLE
State	:	FL
Zip	:	32224
Country	:	US
Telephone Number	:	904-223-3321
Fax Number	:	904-223-2169

Provider Business Practice Location Address
First Line	:	400 CLYDE MORRIS BLVD UNIT B1
Second Line	:
City	:	ORMOND BEACH
State	:	FL
Zip	:	32174-8171
Country	:	US
Telephone Number	:	904-223-3321
Fax Number	:	904-223-2169

Authorized Official
Title or Position	:	CREDENTIALING
Name	:	ALICIA M GROTH
Credential	:
Telephone Number	:	904-223-3321

Provider Enumeration Date	:	06/01/2022
Last Update Date	:	09/23/2022

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Directions to “JACKSONVILLE SPINE CENTER PA ” Practice Location

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