Provider Demographics
NPI:1023685062
Name:INSTITUTE FOR HEALTH SPORTS SPINE REHABILITATION & PAIN MANAGE
Entity type:Organization
Organization Name:INSTITUTE FOR HEALTH SPORTS SPINE REHABILITATION & PAIN MANAGE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:VP OF OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:SHANNON
Authorized Official - Middle Name:
Authorized Official - Last Name:RILEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:904-647-5266
Mailing Address - Street 1:4100 SOUTHPOINT DR E STE 1
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32216-8710
Mailing Address - Country:US
Mailing Address - Phone:904-647-5266
Mailing Address - Fax:904-770-5594
Practice Address - Street 1:3010 E 138TH AVE STE 100
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33613-3902
Practice Address - Country:US
Practice Address - Phone:904-647-5266
Practice Address - Fax:904-770-5594
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-06-08
Last Update Date:2021-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain MedicineGroup - Single Specialty
No2081S0010XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationSports MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL014945000Medicaid