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General NPI Number Information
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NPI Number | 1396526901
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Entity Type | Organization
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Legal Business Name | INTERVENTIONAL SPINE AND PAIN INSTITUTE LLC
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Dates
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Enumeration Date | 10/10/2023
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Last Update Date | 09/26/2025
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Provider Practice Location Address
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Address Line | 5200 BABCOCK ST NE STE 111
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City | PALM BAY
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State | FL
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Zip | 32905-4639
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Country | US
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Telephone | 772-360-1997
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Fax | 772-492-3541
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Provider Business Mailing Address
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Address Line | 777 37TH ST STE C101
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City | VERO BEACH
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State | FL
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Zip | 32960-7301
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Country | US
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Telephone | 772-360-1997
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Fax | 772-492-3541
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Authorized Official
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Title or Position | CREDENTIALING AND CONTRACTING SPECI
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Name | PHAEDRA L SHUDRA
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Credential |
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Telephone | 813-785-4861
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207L00000X
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Taxonomy Name | Anesthesiology Physician
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 207RH0002X
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Taxonomy Name | Hospice and Palliative Medicine (Internal Medicine) Physician
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 207LP2900X
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Taxonomy Name | Pain Medicine (Anesthesiology) Physician
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License Number |
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License Number State |
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Taxonomy #4
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Taxonomy Code | 208VP0000X
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Taxonomy Name | Pain Medicine Physician
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License Number |
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License Number State |
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Taxonomy #5
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Taxonomy Code | 208100000X
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Taxonomy Name | Physical Medicine & Rehabilitation Physician
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License Number |
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License Number State |
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Taxonomy #6
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Taxonomy Code | 208VP0014X
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Taxonomy Name | Interventional Pain Medicine Physician
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License Number |
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License Number State |
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