=====================================================
General NPI Number Information
=====================================================
NPI Number | 1992990170
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GREATER ORLANDO NEURSURGERY AND SPINE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/11/2007
-----------------------------------------------------
Last Update Date | 09/11/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7340 STONEROCK CIR
-----------------------------------------------------
City | ORLANDO
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32819-8000
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 407-355-0575
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7340 STONEROCK CIR
-----------------------------------------------------
City | ORLANDO
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32819-8000
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 407-355-0575
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | NEUROSURGEON
-----------------------------------------------------
Name | MAX BRANDEN MEDARY
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 407-355-0575
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208600000X
-----------------------------------------------------
Taxonomy Name | Surgery Physician
-----------------------------------------------------
License Number | ME58900
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207T00000X
-----------------------------------------------------
Taxonomy Name | Neurological Surgery Physician
-----------------------------------------------------
License Number | ME75973
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------