=====================================================
General NPI Number Information
=====================================================
NPI Number | 1871817395
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FLORIDA SURGICAL SPINE LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/26/2010
-----------------------------------------------------
Last Update Date | 03/29/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1609 PASADENA AVE S SUITE 3-H
-----------------------------------------------------
City | SOUTH PASADENA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33707-4565
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 214-261-3598
-----------------------------------------------------
Fax | 866-466-7913
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4925 GREENVILLE AVE SUITE 200
-----------------------------------------------------
City | DALLAS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75206-4026
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 214-261-3598
-----------------------------------------------------
Fax | 866-466-7913
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CFO
-----------------------------------------------------
Name | STEVEN GANSS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 214-261-3598
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207LP2900X
-----------------------------------------------------
Taxonomy Name | Pain Medicine (Anesthesiology) Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------