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General NPI Number Information
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NPI Number | 1457485666
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Entity Type | Organization
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Legal Business Name | SPINE & SPORTSMEDICINE SPECIALISTS
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Dates
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Enumeration Date | 03/16/2007
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Last Update Date | 11/13/2012
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Provider Practice Location Address
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Address Line | 17327 BALLMONT PARK DR
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City | ODESSA
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State | FL
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Zip | 33556-6209
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Country | US
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Telephone | 904-687-4224
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Fax | 813-852-2137
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Provider Business Mailing Address
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Address Line | 17327 BALLMONT PARK DR
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City | ODESSA
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State | FL
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Zip | 33556-6209
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Country | US
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Telephone | 904-687-4224
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Fax | 813-852-2137
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Authorized Official
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Title or Position | PRESIDENT
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Name | MICHAEL JEROME LORD
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Credential | M.D.
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Telephone | 904-687-4224
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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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