Healthcare Provider Details

I. General information

NPI: 1396526901
Provider Name (Legal Business Name): INTERVENTIONAL SPINE AND PAIN INSTITUTE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/10/2023
Last Update Date: 09/26/2025
Certification Date: 09/26/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5200 BABCOCK ST NE STE 111
PALM BAY FL
32905-4639
US

IV. Provider business mailing address

777 37TH ST STE C101
VERO BEACH FL
32960-7301
US

V. Phone/Fax

Practice location:
  • Phone: 772-360-1997
  • Fax: 772-492-3541
Mailing address:
  • Phone: 772-360-1997
  • Fax: 772-492-3541

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207RH0002X
TaxonomyHospice and Palliative Medicine (Internal Medicine) Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number
License Number State
# 6
Primary TaxonomyY
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: PHAEDRA L SHUDRA
Title or Position: CREDENTIALING AND CONTRACTING SPECI
Credential:
Phone: 813-785-4861