Healthcare Provider Details

I. General information

NPI: 1336400704
Provider Name (Legal Business Name): SPINE INSTITUTE ON THE EMERALD COAST
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/01/2012
Last Update Date: 04/10/2024
Certification Date: 04/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

155 CRYSTAL BEACH DR STE 200
DESTIN FL
32541-3588
US

IV. Provider business mailing address

PO BOX 600366
ST JOHNS FL
32260-0366
US

V. Phone/Fax

Practice location:
  • Phone: 904-717-9625
  • Fax: 904-683-6499
Mailing address:
  • Phone: 904-717-9625
  • Fax: 904-683-6499

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207XS0117X
TaxonomyOrthopaedic Surgery of the Spine Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

Name: AMRISH PATEL
Title or Position: CHIEF MEDICAL OFFICER; OWNER
Credential: MD
Phone: 706-580-3607