NPIMap

Organization Active NPI

Jacksonville Spine Center PA

  • Interventional Pain Medicine Physician
  • St Augustine, FL
National Provider Identifier
1194248229
Registry record updated Sep 26, 2022
On this page

Key facts

NPPES NPI Registry
Primary specialty
Interventional Pain Medicine PhysicianTaxonomy code 208VP0014X
Legal business name
JACKSONVILLE SPINE CENTER PA
Practice address
1100 Plantation Island Dr S Ste 220
St Augustine, FL 32080-5174
Phone
(904) 223-3321
Fax
(904) 223-2169
NPI assigned
Jul 20, 2017
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Sep 26, 2022

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

Authorized official

Name
Alicia Groth
Title
Credentialing Specialist
Phone
(904) 223-3321

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Interventional Pain Medicine PhysicianGroup: 193400000X SINGLE SPECIALTY GROUP 208VP0014X Primary

Addresses

Primary practice location

1100 Plantation Island Dr S Ste 220
St Augustine, FL 32080-5174

Mailing address

5191 First Coast Tech Pkwy
3Rd Floor
Jacksonville, FL 32224
Phone (904) 223-3321

Other names 1

  • Jax Spine & Pain Centers Doing business as

Medicare participation

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

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20171102002814 FL DME Supplier - Physician - AnesthesiologyDME Supplier - Physician - Interventional Pain Management 6901890300 Practice locations: St Augustine, FL

Other NPIs with the same Medicare PAC ID 7

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

National Provider Directory

National Provider Directory
Tax ID family
Jacksonville Spine Center PA8 organizations share this tax ID, including this one

Other organizations with this tax ID 7

Organizations that report the same tax identification number in the National Provider Directory.

NPI Registry JSON

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

{
    "created_epoch": "1500508800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1664150400000",
    "number": "1194248229",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "5191 FIRST COAST TECH PKWY",
            "address_2": "3RD FLOOR",
            "city": "JACKSONVILLE",
            "state": "FL",
            "postal_code": "32224",
            "telephone_number": "904-223-3321",
            "fax_number": "904-223-2169"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1100 PLANTATION ISLAND DR S STE 220",
            "city": "ST AUGUSTINE",
            "state": "FL",
            "postal_code": "320805174",
            "telephone_number": "904-223-3321",
            "fax_number": "904-223-2169"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "JACKSONVILLE SPINE CENTER PA",
        "organizational_subpart": "NO",
        "enumeration_date": "2017-07-20",
        "last_updated": "2022-09-26",
        "certification_date": "2022-09-20",
        "status": "A",
        "authorized_official_last_name": "GROTH",
        "authorized_official_first_name": "ALICIA",
        "authorized_official_title_or_position": "CREDENTIALING SPECIALIST",
        "authorized_official_telephone_number": "904-223-3321"
    },
    "taxonomies": [
        {
            "code": "208VP0014X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Pain Medicine, Interventional Pain Medicine",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Jax Spine & Pain Centers",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in St Augustine, FL

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Sep 26, 2022; 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.