Healthcare Provider Details

I. General information

NPI: 1609548254
Provider Name (Legal Business Name): NORTH FLORIDA ORTHOPEDIC AND SPINE, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/01/2021
Last Update Date: 05/25/2023
Certification Date: 05/25/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

657 E ROMANA ST
PENSACOLA FL
32502-6111
US

IV. Provider business mailing address

4400 STATE HIGHWAY 121 STE 405
LEWISVILLE TX
75056
US

V. Phone/Fax

Practice location:
  • Phone: 850-446-2909
  • Fax:
Mailing address:
  • Phone: 469-459-9754
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207XS0117X
TaxonomyOrthopaedic Surgery of the Spine Physician
License Number
License Number State

VIII. Authorized Official

Name: SETH JACKNOWITZ
Title or Position: CRO
Credential:
Phone: 469-459-9754