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General NPI Number Information
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NPI Number | 1396072765
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Entity Type | Organization
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Legal Business Name | THE SPINE INSTITUTE AT ORTHOPAEDIC ASSOCIATES PL
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Dates
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Enumeration Date | 11/05/2009
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Last Update Date | 06/02/2012
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Provider Practice Location Address
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Address Line | 1034 MAR WALT DR SUITE 310
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City | FORT WALTON BEACH
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State | FL
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Zip | 32547-6645
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Country | US
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Telephone | 850-797-6027
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Fax | 850-797-6027
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Provider Business Mailing Address
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Address Line | 1034 MAR WALT DR SUITE 310
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City | FORT WALTON BEACH
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State | FL
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Zip | 32547-6645
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Country | US
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Telephone | 850-797-6027
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Fax | 850-797-6027
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Authorized Official
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Title or Position | PHYSICIAN
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Name | DR. KORNELIS A POELSTRA
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Credential | MD
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Telephone | 850-797-6027
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207X00000X
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Taxonomy Name | Orthopaedic Surgery Physician
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License Number |
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License Number State |
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