Healthcare Provider Details

I. General information

NPI: 1881643757
Provider Name (Legal Business Name): JACKSONVILLE SPINE CENTER PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/09/2006
Last Update Date: 05/09/2023
Certification Date: 05/09/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5191 FIRST COAST TECH PKWY
JACKSONVILLE FL
32224
US

IV. Provider business mailing address

5191 FIRST COAST TECH PKWY 3RD FLOOR
JACKSONVILLE FL
32224
US

V. Phone/Fax

Practice location:
  • Phone: 904-223-3321
  • Fax: 904-223-2169
Mailing address:
  • Phone: 904-223-3321
  • Fax: 904-223-2169

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number
License Number State

VIII. Authorized Official

Name: ALICIA M GROTH
Title or Position: CREDENTIALING SPECIALIST
Credential:
Phone: 904-223-3321