Healthcare Provider Details

I. General information

NPI: 1720207749
Provider Name (Legal Business Name): SPINE MEDICAL CENTER,LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/25/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9344 THREE RIVERS RD
GULFPORT MS
39503-4268
US

IV. Provider business mailing address

PO BOX 2156
GULFPORT MS
39505-2156
US

V. Phone/Fax

Practice location:
  • Phone: 228-865-4731
  • Fax: 228-863-5616
Mailing address:
  • Phone: 228-865-4731
  • Fax: 228-863-5616

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number12692
License Number StateMS

VIII. Authorized Official

Name: DR. JOEL BERMAN BURWELL
Title or Position: DR.
Credential: D.O.
Phone: 228-865-4731