MEDICARE: SPINE CENTER OF FL 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	208VP0000X	Pain Medicine Physician
2	208VP0014X	Interventional Pain Medicine Physician

General Provider Information

NPI Number	:	1699326744
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SPINE CENTER OF FL LLC

Provider Business Mailing Address
First Line	:	11921 ROCKVILLE PIKE STE 505
Second Line	:
City	:	ROCKVILLE
State	:	MD
Zip	:	20852-2758
Country	:	US
Telephone Number	:	703-789-1929
Fax Number	:

Provider Business Practice Location Address
First Line	:	1031 SE 9TH PL
Second Line	:
City	:	CAPE CORAL
State	:	FL
Zip	:	33990-3003
Country	:	US
Telephone Number	:	239-333-1177
Fax Number	:	239-333-1169

Authorized Official
Title or Position	:	OFFICER
Name	:	DOUGLAS W WISOR
Credential	:	MD
Telephone Number	:	703-927-5772

Provider Enumeration Date	:	09/20/2019
Last Update Date	:	09/20/2019

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Directions to “SPINE CENTER OF FL LLC ” Practice Location

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