Healthcare Provider Details

I. General information

NPI: 1356396774
Provider Name (Legal Business Name): MICROSPINE PHYSICIANS GROUP LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/24/2006
Last Update Date: 10/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 MICROSPINE WAY
DEFUNIAK SPRINGS FL
32435-6323
US

IV. Provider business mailing address

101 MICROSPINE WAY
DEFUNIAK SPRINGS FL
32435-6323
US

V. Phone/Fax

Practice location:
  • Phone: 850-892-6001
  • Fax: 850-892-4212
Mailing address:
  • Phone: 850-892-6001
  • Fax: 850-892-4212

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RS0010X
TaxonomySports Medicine (Internal Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: ANGEL D BARBER
Title or Position: ADMINISTRATOR
Credential:
Phone: 850-892-6001