MEDICARE: BEACHES BEHAVIORAL MEDICINE

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	2084P0804X	Child & Adolescent Psychiatry Physician
2	2084P2900X	Pain Medicine (Psychiatry & Neurology) Physician
3	207QA0401X	Addiction Medicine (Family Medicine) Physician	ME115625	FL
4	2083A0300X	Addiction Medicine (Preventive Medicine) Physician
5	2084A0401X	Addiction Medicine (Psychiatry & Neurology) Physician
6	2084P0800X	Psychiatry Physician
7	208VP0000X	Pain Medicine Physician
8	208VP0014X	Interventional Pain Medicine Physician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1417309832
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BEACHES BEHAVIORAL MEDICINE

Provider Business Mailing Address
First Line	:	PO BOX 1557
Second Line	:
City	:	PONTE VEDRA BEACH
State	:	FL
Zip	:	32004-1557
Country	:	US
Telephone Number	:	904-280-6701
Fax Number	:	904-280-6702

Provider Business Practice Location Address
First Line	:	1351 13TH AVE S STE 120
Second Line	:
City	:	JACKSONVILLE BEACH
State	:	FL
Zip	:	32250-3237
Country	:	US
Telephone Number	:	904-280-6701
Fax Number	:	904-280-6702

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. JUSTIN KUHNS SPOONER
Credential	:	MD
Telephone Number	:	904-280-6701

Provider Enumeration Date	:	07/09/2016
Last Update Date	:	01/12/2023

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Practice Location Address:

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1013301696 — ANTHONY L CAPASSO MD PRIMARY CARE
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1245614114 — SHANNON JANE O'BRIEN F.N.P.
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1417629106 — MILLENNIUM PHYSICIAN GROUP LLC
Practice Location Address:

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1609586858 — JACKSONVILLE SPINE CENTER PA
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