MEDICARE: DYNAMIC SPINAL IMAGING OF BATON ROUGE, 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	261QP3300X	Pain Clinic/Center
2	261QR0200X	Radiology Clinic/Center

General Provider Information

NPI Number	:	1780135632
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DYNAMIC SPINAL IMAGING OF BATON ROUGE, LLC

Provider Business Mailing Address
First Line	:	7922 SUMMA AVE
Second Line	:	SUITE 4
City	:	BATON ROUGE
State	:	LA
Zip	:	70809-3475
Country	:	US
Telephone Number	:	337-244-3590
Fax Number	:

Provider Business Practice Location Address
First Line	:	7922 SUMMA AVE
Second Line	:	SUITE 4
City	:	BATON ROUGE
State	:	LA
Zip	:	70809-3475
Country	:	US
Telephone Number	:	337-244-3590
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. JOHN CONDOS
Credential	:	PHD
Telephone Number	:	337-244-3590

Provider Enumeration Date	:	10/16/2016
Last Update Date	:	10/16/2016

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