=====================================================
General NPI Number Information
=====================================================
NPI Number | 1326187667
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BRAIN & SPINE NEUROSURGERY, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/05/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1050 SE MONTEREY RD SUITE #102
-----------------------------------------------------
City | STUART
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34994-4512
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 772-463-4033
-----------------------------------------------------
Fax | 772-463-4034
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1050 SE MONTEREY RD SUITE #102
-----------------------------------------------------
City | STUART
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34994-4512
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 772-463-4033
-----------------------------------------------------
Fax | 772-463-4034
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGER
-----------------------------------------------------
Name | MRS. JODI L. DUDENEY
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 772-463-4033
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QH0100X
-----------------------------------------------------
Taxonomy Name | Health Service Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------