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General NPI Number Information
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NPI Number | 1699016949
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Entity Type | Organization
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Legal Business Name | BRAIN AND SPINE INSTITUTE OF PORT ORANGE, LLC
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Dates
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Enumeration Date | 03/12/2013
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Last Update Date | 03/15/2013
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Provider Practice Location Address
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Address Line | 1211 DUNLAWTON AVE
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City | PORT ORANGE
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State | FL
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Zip | 32127-2913
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Country | US
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Telephone | 386-304-0111
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Fax |
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Provider Business Mailing Address
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Address Line | 1211 DUNLAWTON AVE
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City | PORT ORANGE
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State | FL
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Zip | 32127-2913
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Country | US
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Telephone | 386-304-0111
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Fax |
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Authorized Official
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Title or Position | CEO
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Name | DR. TIMOTHY JOSEPH WIERZBICKI
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Credential | M.D.
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Telephone | 386-304-0111
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2084N0400X
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Taxonomy Name | Neurology Physician
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License Number | ME80334
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License Number State | FL
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