Healthcare Provider Details

I. General information

NPI: 1396154118
Provider Name (Legal Business Name): INTERVENTIONAL SPINE INSTITUTE OF FLORIDA, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/06/2014
Last Update Date: 03/07/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1315 S INTERNATIONAL PKWY SUITE 1111
LAKE MARY FL
32746-1407
US

IV. Provider business mailing address

308 S HARBOR CITY BLVD SUITE A
MELBOURNE FL
32901-1500
US

V. Phone/Fax

Practice location:
  • Phone: 321-733-0064
  • Fax: 321-733-7970
Mailing address:
  • Phone: 321-733-0064
  • Fax: 321-733-7970

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number60952
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number60952
License Number StateFL

VIII. Authorized Official

Name: DR. BRIAN C DOWDELL
Title or Position: OWNER/CEO/PRESIDENT
Credential: M.D.
Phone: 321-733-0064