1255373882 NPI number — NEUROSPINAL SURGERY, PC

Table of content: (NPI 1255373882)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1255373882 NPI number — NEUROSPINAL SURGERY, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NEUROSPINAL SURGERY, PC
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:
1255373882
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/05/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 4520
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CAROL STREAM
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60197-4520
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
314-432-2580
Provider Business Mailing Address Fax Number:
314-991-8960

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
226 S WOODS MILL RD
Provider Second Line Business Practice Location Address:
SUITE 54 W
Provider Business Practice Location Address City Name:
CHESTERFIELD
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
63017-3662
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
314-388-6513
Provider Business Practice Location Address Fax Number:
314-878-0847
Provider Enumeration Date:
06/11/2006

Additional Information

Authorized Official

Authorized Official Last Name:
JORDAN
Authorized Official First Name:
JACKI
Authorized Official Middle Name:
Authorized Official Title or Position:
BILLING MANAGER
Authorized Official Telephone Number:
314-432-2580

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  R4651 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: DB5175 . This is a "RR MEDICARE GROUP#" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 000014163 . This is a "MEDICARE PTAN" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".




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