MEDICARE: MISSOURI SPINE ASSOCIATES, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208D00000X	General Practice Physician	2006037124	MO

General Provider Information

NPI Number	:	1649565961
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MISSOURI SPINE ASSOCIATES, LLC

Provider Business Mailing Address
First Line	:	1765 JEFFCO BLVD
Second Line	:
City	:	ARNOLD
State	:	MO
Zip	:	63010-2713
Country	:	US
Telephone Number	:	636-333-3700
Fax Number	:	636-333-3701

Provider Business Practice Location Address
First Line	:	1765 JEFFCO BLVD
Second Line	:
City	:	ARNOLD
State	:	MO
Zip	:	63010-2713
Country	:	US
Telephone Number	:	636-333-3700
Fax Number	:	636-333-3701

Authorized Official
Title or Position	:	OWNER
Name	:	ABIRAMI ELANGOVAN
Credential	:
Telephone Number	:	636-333-3700

Provider Enumeration Date	:	06/15/2011
Last Update Date	:	11/15/2016

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