Healthcare Provider Details

I. General information

NPI: 1508101296
Provider Name (Legal Business Name): TAMPA INTERVENTIONAL SPINE PHYSICIANS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/06/2012
Last Update Date: 12/07/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 W KENNEDY BLVD SUITE 201
TAMPA FL
33606-1940
US

IV. Provider business mailing address

1000 W KENNEDY BLVD SUITE 201
TAMPA FL
33606-1940
US

V. Phone/Fax

Practice location:
  • Phone: 813-258-2225
  • Fax: 813-258-8118
Mailing address:
  • Phone: 813-258-2225
  • Fax: 813-258-8118

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number98264
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code207RA0401X
TaxonomyAddiction Medicine (Internal Medicine) Physician
License Number105149
License Number StateFL
# 3
Primary TaxonomyY
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number105149
License Number StateFL

VIII. Authorized Official

Name: KORTNI FLYNN
Title or Position: OWNER
Credential:
Phone: 989-714-1839