1053451864 NPI number — INNOVATIVE NEURO SPINE INC

Table of content: (NPI 1053451864)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053451864 NPI number — INNOVATIVE NEURO SPINE INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
INNOVATIVE NEURO SPINE INC
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:
6
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:
1053451864
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9898 BISSONNET
Provider Second Line Business Mailing Address:
# 152
Provider Business Mailing Address City Name:
HOUSTON
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
77036-8025
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
713-271-7373
Provider Business Mailing Address Fax Number:
713-271-2219

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9898 BISSONNET
Provider Second Line Business Practice Location Address:
# 152
Provider Business Practice Location Address City Name:
HOUSTON
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
77036-8025
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
713-271-7373
Provider Business Practice Location Address Fax Number:
713-271-2219
Provider Enumeration Date:
02/08/2007

Additional Information

Authorized Official

Authorized Official Last Name:
PRUSHESH
Authorized Official First Name:
MAHMOOD
Authorized Official Middle Name:
Authorized Official Title or Position:
DOCTOR
Authorized Official Telephone Number:
713-271-7373

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  8473 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 831282 . This is a "BCBS" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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