=====================================================
General NPI Number Information
=====================================================
NPI Number | 1386334944
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SEVEN BRIDGES PAIN SPECIALISTS LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/08/2023
-----------------------------------------------------
Last Update Date | 09/11/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4745 SUTTON PARK CT STE 501
-----------------------------------------------------
City | JACKSONVILLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32224-0251
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-503-5464
-----------------------------------------------------
Fax | 904-575-4399
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2023 MYRA ST
-----------------------------------------------------
City | JACKSONVILLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32204-3714
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-503-5464
-----------------------------------------------------
Fax | 904-575-4399
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | RENEE A GALLO
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 904-503-5464
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208VP0014X
-----------------------------------------------------
Taxonomy Name | Interventional Pain Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------