NPIMap

Organization Active NPI

Interventional Spine and Pain Institute LLC

  • Interventional Pain Medicine Physician
  • Melbourne, FL
National Provider Identifier
1093695504
Registry record updated Sep 26, 2025
On this page

Key facts

NPPES NPI Registry
Primary specialty
Interventional Pain Medicine PhysicianTaxonomy code 208VP0014X
Legal business name
INTERVENTIONAL SPINE AND PAIN INSTITUTE LLC
Practice address
6559 N Wickham Rd
Melbourne, FL 32940-2052
Phone
(772) 360-1997
Fax
(772) 492-3541
NPI assigned
Sep 4, 2025
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Sep 26, 2025

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Phaedra L Shudra
Title
Credentialing and Contracting Speci
Phone
(813) 785-4861

Specialties & licenses 6

Specialty (taxonomy)CodeLicenseStatePrimary
Anesthesiology PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 207L00000X
Pain Medicine (Anesthesiology) PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 207LP2900X
Hospice and Palliative Medicine (Internal Medicine) PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 207RH0002X
Physical Medicine & Rehabilitation PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 208100000X
Pain Medicine PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 208VP0000X
Interventional Pain Medicine PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 208VP0014X Primary

Addresses

Primary practice location

6559 N Wickham Rd
Melbourne, FL 32940-2052

Mailing address

777 37TH St Ste C101
Vero Beach, FL 32960-7301
Phone (772) 360-1997

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in FL

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20260124000426 FL DME Supplier - Physician - Interventional Pain Management 2365836582 Practice locations: Melbourne, FL

Other NPIs with the same Medicare PAC ID 1

NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).

National Provider Directory

National Provider Directory

Locations

6559 N Wickham Rd
Melbourne, FL 32940
Phone (772) 360-1997

6559 N Wickham Rd
Ste 102
Melbourne, FL 32940
Phone (772) 360-1997

Practitioners & affiliated clinicians

Practitioners 7

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1756944000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1758844800000",
    "number": "1093695504",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "777 37TH ST STE C101",
            "city": "VERO BEACH",
            "state": "FL",
            "postal_code": "329607301",
            "telephone_number": "772-360-1997",
            "fax_number": "772-492-3541"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "6559 N WICKHAM RD",
            "city": "MELBOURNE",
            "state": "FL",
            "postal_code": "329402052",
            "telephone_number": "772-360-1997",
            "fax_number": "772-492-3541"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "INTERVENTIONAL SPINE AND PAIN INSTITUTE LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2025-09-04",
        "last_updated": "2025-09-26",
        "certification_date": "2025-09-26",
        "status": "A",
        "authorized_official_last_name": "SHUDRA",
        "authorized_official_first_name": "PHAEDRA",
        "authorized_official_middle_name": "L",
        "authorized_official_title_or_position": "CREDENTIALING AND CONTRACTING SPECI",
        "authorized_official_telephone_number": "813-785-4861"
    },
    "taxonomies": [
        {
            "code": "207L00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Anesthesiology",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "207LP2900X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Anesthesiology, Pain Medicine",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "207RH0002X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Internal Medicine, Hospice and Palliative Medicine",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "208100000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Physical Medicine & Rehabilitation",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "208VP0000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Pain Medicine, Pain Medicine",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "208VP0014X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Pain Medicine, Interventional Pain Medicine",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Melbourne, FL

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Sep 26, 2025; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.