MEDICARE: ORTHOPAEDIC AND SPINE MEDICAL GROUP, INC

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	111NR0400X	Rehabilitation Chiropractor	CH8833	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	CH8833	OTHER	FL	STATE LICENSE
2	1801022215	OTHER		NPI

General Provider Information

NPI Number	:	1326462417
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ORTHOPAEDIC AND SPINE MEDICAL GROUP, INC

Provider Business Mailing Address
First Line	:	435 W OAK ST
Second Line	:
City	:	KISSIMMEE
State	:	FL
Zip	:	34741-6627
Country	:	US
Telephone Number	:	407-530-4734
Fax Number	:

Provider Business Practice Location Address
First Line	:	435 W OAK ST
Second Line	:
City	:	KISSIMMEE
State	:	FL
Zip	:	34741-6627
Country	:	US
Telephone Number	:	407-530-4734
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	KEITH MASSI
Credential	:	D.C.
Telephone Number	:	407-530-4734

Provider Enumeration Date	:	02/10/2014
Last Update Date	:	02/10/2014

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