Provider Demographics
NPI:1053719393
Name:PCA INTERVENTIONAL SPINE AT MACQUARIUM
Entity type:Organization
Organization Name:PCA INTERVENTIONAL SPINE AT MACQUARIUM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:RODRIGO
Authorized Official - Middle Name:
Authorized Official - Last Name:DURALDE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:404-351-7654
Mailing Address - Street 1:PO BOX 40166
Mailing Address - Street 2:
Mailing Address - City:BELFAST
Mailing Address - State:ME
Mailing Address - Zip Code:04915-1241
Mailing Address - Country:US
Mailing Address - Phone:888-488-8289
Mailing Address - Fax:502-919-9780
Practice Address - Street 1:1800 PEACHTREE ST NW
Practice Address - Street 2:SUITE 775
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30309-2519
Practice Address - Country:US
Practice Address - Phone:404-351-7654
Practice Address - Fax:770-692-6082
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-12-19
Last Update Date:2025-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP3300XAmbulatory Health Care FacilitiesClinic/CenterPain
No261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical