=====================================================
General NPI Number Information
=====================================================
NPI Number | 1124273529
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SUNSHINE SPINE AND PAIN, PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/26/2008
-----------------------------------------------------
Last Update Date | 04/29/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3 SHIRCLIFF WAY SUITE 610
-----------------------------------------------------
City | JACKSONVILLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32204-4757
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-292-2700
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 919327
-----------------------------------------------------
City | ORLANDO
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32891-9327
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-292-2700
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRACTICE ADMINISTRATOR
-----------------------------------------------------
Name | TERESA FRIEDLEY
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 904-292-2700
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2081P2900X
-----------------------------------------------------
Taxonomy Name | Pain Medicine (Physical Medicine & Rehabilitation) Physician
-----------------------------------------------------
License Number | ME84002
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------