1750516704 NPI number — SPINE SPORTS AND PAIN MEDICINE, PC

Table of content: (NPI 1750516704)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1750516704 NPI number — SPINE SPORTS AND PAIN MEDICINE, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SPINE SPORTS AND PAIN MEDICINE, 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:
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:
1750516704
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/20/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 8857
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FORT WAYNE
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46898-8857
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
260-969-6200
Provider Business Mailing Address Fax Number:
260-969-6201

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7900 W JEFFERSON BLVD
Provider Second Line Business Practice Location Address:
SUITE 304
Provider Business Practice Location Address City Name:
FORT WAYNE
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46804-4128
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
260-969-6200
Provider Business Practice Location Address Fax Number:
260-969-6201
Provider Enumeration Date:
05/20/2009

Additional Information

Authorized Official

Authorized Official Last Name:
CAVACINI
Authorized Official First Name:
MATTHEW
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
260-969-6200

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X , with the licence number:  50004446A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





Copyright © 2007-2025 www.npivalidator.com