1558754705 NPI number — NEUROSURGICAL AND SPINE CONSULTANTS, 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 1558754705 NPI number — NEUROSURGICAL AND SPINE CONSULTANTS, PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NEUROSURGICAL AND SPINE CONSULTANTS, 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:
1558754705
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/02/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1001 12TH AVE STE 171
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FORT WORTH
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
76104-3926
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
817-576-6500
Provider Business Mailing Address Fax Number:
682-703-2064

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1001 12TH AVE
Provider Second Line Business Practice Location Address:
STE 170
Provider Business Practice Location Address City Name:
FT WORTH
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76104-3926
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
214-373-3183
Provider Business Practice Location Address Fax Number:
214-361-5601
Provider Enumeration Date:
03/12/2015

Additional Information

Authorized Official

Authorized Official Last Name:
WILSON
Authorized Official First Name:
DIANA
Authorized Official Middle Name:
E
Authorized Official Title or Position:
OWNER/PHYSCIAN
Authorized Official Telephone Number:
817-576-6500

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  J0729 , 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)





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