MEDICARE: SPINE CENTER OF SOUTHEAST GEORGIA 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	208VP0014X	Interventional Pain Medicine Physician

General Provider Information

NPI Number	:	1639270903
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SPINE CENTER OF SOUTHEAST GEORGIA LLC

Provider Business Mailing Address
First Line	:	4960 SW 72ND AVE STE 405
Second Line	:
City	:	MIAMI
State	:	FL
Zip	:	33155-5506
Country	:	US
Telephone Number	:	469-458-9222
Fax Number	:	540-918-7202

Provider Business Practice Location Address
First Line	:	1111 GLYNCO PKWY
Second Line	:	STE 300
City	:	BRUNSWICK
State	:	GA
Zip	:	31525-7921
Country	:	US
Telephone Number	:	912-262-6552
Fax Number	:	912-262-0112

Authorized Official
Title or Position	:	RCM MANAGER
Name	:	SHANEKA TINCH
Credential	:
Telephone Number	:	469-458-9222

Provider Enumeration Date	:	09/26/2006
Last Update Date	:	12/08/2025

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