MEDICARE: INTERVENTIONAL SPINE AND PAIN INSTITUTE LLC

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy
1	207L00000X	Anesthesiology Physician
2	207RH0002X	Hospice and Palliative Medicine (Internal Medicine) Physician
3	207LP2900X	Pain Medicine (Anesthesiology) Physician
4	208VP0000X	Pain Medicine Physician
5	208100000X	Physical Medicine & Rehabilitation Physician
6	208VP0014X	Interventional Pain Medicine Physician

General Provider Information

NPI Number	:	1396526901
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	INTERVENTIONAL SPINE AND PAIN INSTITUTE LLC

Provider Business Mailing Address
First Line	:	777 37TH ST STE C101
Second Line	:
City	:	VERO BEACH
State	:	FL
Zip	:	32960-7301
Country	:	US
Telephone Number	:	772-360-1997
Fax Number	:	772-492-3541

Provider Business Practice Location Address
First Line	:	5200 BABCOCK ST NE STE 111
Second Line	:
City	:	PALM BAY
State	:	FL
Zip	:	32905-4639
Country	:	US
Telephone Number	:	772-360-1997
Fax Number	:	772-492-3541

Authorized Official
Title or Position	:	CREDENTIALING AND CONTRACTING SPECI
Name	:	PHAEDRA L SHUDRA
Credential	:
Telephone Number	:	813-785-4861

Provider Enumeration Date	:	10/10/2023
Last Update Date	:	09/26/2025

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Directions to “INTERVENTIONAL SPINE AND PAIN INSTITUTE LLC ” Practice Location

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