1366761793 NPI number — PERFORMANCE SPINE & SPORTS SPECIALISTS, PA

Table of content: (NPI 1366761793)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1366761793 NPI number — PERFORMANCE SPINE & SPORTS SPECIALISTS, PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PERFORMANCE SPINE & SPORTS 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:
1366761793
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/01/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 38728
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GREENSBORO
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
27438-8728
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
336-501-3796
Provider Business Mailing Address Fax Number:
336-333-5477

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1507 WESTOVER TER STE B
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
GREENSBORO
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27408-7121
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
336-501-3796
Provider Business Practice Location Address Fax Number:
336-333-5477
Provider Enumeration Date:
05/25/2010

Additional Information

Authorized Official

Authorized Official Last Name:
DALTON-BETHEA
Authorized Official First Name:
SHAWN
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
336-501-3796

Provider Taxonomy Codes

  • Taxonomy code: 2081P2900X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 5909458 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".




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