1194817825 NPI number — SPINE SPECIALISTS, PA

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1194817825 NPI number — SPINE SPECIALISTS, PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SPINE SPECIALISTS, PA
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1194817825
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/03/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 9984
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TYLER
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75711
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
903-593-2222
Provider Business Mailing Address Fax Number:
903-593-0142

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1814 ROSELAND BLVD.
Provider Second Line Business Practice Location Address:
SUITE 250
Provider Business Practice Location Address City Name:
TYLER
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75701
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
903-593-2222
Provider Business Practice Location Address Fax Number:
903-593-0142
Provider Enumeration Date:
09/29/2006

Additional Information

Authorized Official

Authorized Official Last Name:
PAUZA
Authorized Official First Name:
KEVIN
Authorized Official Middle Name:
JOSEPH
Authorized Official Title or Position:
PHYSICIAN/OWNER
Authorized Official Telephone Number:
903-593-2222

Provider Taxonomy Codes

  • Taxonomy code: 208100000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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