MEDICARE: NEUROLOGY & SPINE DISORDERS 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	2084N0400X	Neurology Physician	ME46005	FL

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	DQ2689	OTHER	FL	RAILROAD MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	000EZ	OTHER	FL	BLUE CROSS BLUE SHIELD

General Provider Information

NPI Number	:	1790008811
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NEUROLOGY & SPINE DISORDERS LLC

Provider Business Mailing Address
First Line	:	1673 MASON AVE
Second Line	:	SUITE 107
City	:	DAYTONA BEACH
State	:	FL
Zip	:	32117-5515
Country	:	US
Telephone Number	:	386-274-7118
Fax Number	:	386-274-6173

Provider Business Practice Location Address
First Line	:	5111 S RIDGEWOOD AVE
Second Line	:	SUITE 102
City	:	PORT ORANGE
State	:	FL
Zip	:	32127-5169
Country	:	US
Telephone Number	:	386-763-4484
Fax Number	:	386-763-1288

Authorized Official
Title or Position	:	CEO
Name	:	MR. AL FALCO
Credential	:
Telephone Number	:	386-274-7118

Provider Enumeration Date	:	03/03/2010
Last Update Date	:	09/08/2010

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Directions to “NEUROLOGY & SPINE DISORDERS LLC ” Practice Location

Language	Start Address	Practice Location

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