NPIMap

Organization Active NPI

Jacksonville Spine Center PA

Doing business as Jax Spine & Pain Centers

  • Interventional Pain Medicine Physician
  • Fleming Island, FL
National Provider Identifier
1912560798
Registry record updated Sep 23, 2022
On this page

Key facts

NPPES NPI Registry
Primary specialty
Interventional Pain Medicine PhysicianTaxonomy code 208VP0014X
Legal business name
JACKSONVILLE SPINE CENTER PA
Doing business as
Jax Spine & Pain Centers
Practice address
2349 Village Square Pkwy Ste 107
Fleming Island, FL 32003-4319
Phone
(904) 223-3321
Fax
(904) 223-2169
NPI assigned
Apr 17, 2019
Last updated
Sep 23, 2022By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Sep 23, 2022

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

Authorized official

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

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Interventional Pain Medicine Physician 208VP0014X Primary

Addresses

Primary practice location

2349 Village Square Pkwy Ste 107
Fleming Island, FL 32003-4319

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
O20210512002693 FL DME Supplier - Physician - Interventional Pain ManagementDME Supplier - Other 6901890300 Practice locations: Fleming Island, FL

Other NPIs with the same Medicare PAC ID 7

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

Laboratory certificates & supplier records

Derived by NPIMap

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

Medicare medical equipment & supply locations

SupplierSuppliesMedicare assignment
Jax Spine & Pain Centers2349 Village Square Pkwy, Fleming Island, FL 32003-4319(904) 223-3321 Orthoses: Custom Fabricated|Orthoses: Prefabricated (Non-Custom Fabricated)|Orthoses: Off-The-Shelf Accepts assignmentParticipating since Jan 1, 2004

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.

Locations

2349 Village Square Pkwy
Ste 107
Fleming Island, FL 32003
Phone (904) 257-0060

NPI Registry JSON

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

{
    "created_epoch": "1555459200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1663891200000",
    "number": "1912560798",
    "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": "2349 VILLAGE SQUARE PKWY STE 107",
            "city": "FLEMING ISLAND",
            "state": "FL",
            "postal_code": "320034319",
            "telephone_number": "904-223-3321",
            "fax_number": "904-223-2169"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "JACKSONVILLE SPINE CENTER PA",
        "organizational_subpart": "NO",
        "enumeration_date": "2019-04-17",
        "last_updated": "2022-09-23",
        "certification_date": "2022-09-20",
        "status": "A",
        "authorized_official_last_name": "GROTH",
        "authorized_official_first_name": "ALICIA",
        "authorized_official_middle_name": "M",
        "authorized_official_title_or_position": "CREDENTIALING SPECIALIST",
        "authorized_official_telephone_number": "904-223-3321"
    },
    "taxonomies": [
        {
            "code": "208VP0014X",
            "taxonomy_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 Fleming Island, FL

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Sep 23, 2022; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.