Healthcare Provider Details

I. General information

NPI: 1356108989
Provider Name (Legal Business Name): INTEGRITY SPINE AND ORTHOPEDICS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/29/2024
Last Update Date: 08/30/2024
Certification Date: 08/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1811 BLANDING BLVD STE 102
MIDDLEBURG FL
32068-4935
US

IV. Provider business mailing address

14785 OLD SAINT AUGUSTINE RD STE 100
JACKSONVILLE FL
32258-7407
US

V. Phone/Fax

Practice location:
  • Phone: 904-456-0017
  • Fax: 904-456-0018
Mailing address:
  • Phone: 904-456-0017
  • Fax: 904-456-0018

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207T00000X
TaxonomyNeurological Surgery Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207XS0117X
TaxonomyOrthopaedic Surgery of the Spine Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number
License Number State
# 7
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

Name: MATTHEW TERRY
Title or Position: PRESIDENT/COO
Credential:
Phone: 904-456-0017