Healthcare Provider Details

I. General information

NPI: 1639364912
Provider Name (Legal Business Name): SOUTH PALM ORTHOSPINE INSTITUTE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/11/2007
Last Update Date: 09/24/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2900 N MILITARY TRL #241
BOCA RATON FL
33431-6365
US

IV. Provider business mailing address

6110 W ATLANTIC AVE UNIT A
DELRAY BEACH FL
33484-8405
US

V. Phone/Fax

Practice location:
  • Phone: 561-742-5959
  • Fax: 561-732-0553
Mailing address:
  • Phone: 561-742-5959
  • Fax: 561-732-0553

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207XS0117X
TaxonomyOrthopaedic Surgery of the Spine Physician
License NumberME55593
License Number StateFL

VIII. Authorized Official

Name: STEWART EIDELSON
Title or Position: OWNER
Credential: M.D.
Phone: 561-742-5959