MEDICARE: GULFCOAST SPINE INSTITUTE, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207T00000X	Neurological Surgery Physician
2	207XS0117X	Orthopaedic Surgery of the Spine Physician

General Provider Information

NPI Number	:	1174040828
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GULFCOAST SPINE INSTITUTE, LLC

Provider Business Mailing Address
First Line	:	4211 W BOY SCOUT BLVD STE 400
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33607-5766
Country	:	US
Telephone Number	:	813-443-2108
Fax Number	:	813-284-7952

Provider Business Practice Location Address
First Line	:	3902 MILLENIA BLVD STE 300
Second Line	:
City	:	ORLANDO
State	:	FL
Zip	:	32839-6407
Country	:	US
Telephone Number	:	813-443-2108
Fax Number	:	813-284-7952

Authorized Official
Title or Position	:	OWNER
Name	:	JAMES J RONZO
Credential	:	DO
Telephone Number	:	813-443-2108

Provider Enumeration Date	:	08/24/2017
Last Update Date	:	11/07/2023

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