=====================================================
General NPI Number Information
=====================================================
NPI Number | 1992055131
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SPINE AND BRAIN SURGERY, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/14/2012
-----------------------------------------------------
Last Update Date | 10/23/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5341 W ATLANTIC AVE STE 302
-----------------------------------------------------
City | DELRAY BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33484
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 561-403-5175
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5341 W ATLANTIC AVE STE 302
-----------------------------------------------------
City | DELRAY BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33484-8166
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 561-403-5175
-----------------------------------------------------
Fax | 866-313-8923
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATION
-----------------------------------------------------
Name | MRS. MARY NEWELL
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 561-403-5175
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207T00000X
-----------------------------------------------------
Taxonomy Name | Neurological Surgery Physician
-----------------------------------------------------
License Number | ME98749
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------