MEDICARE: US SPINE PLLC

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	207XS0117X	Orthopaedic Surgery of the Spine Physician

General Provider Information

NPI Number	:	1871136218
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	US SPINE PLLC

Provider Business Mailing Address
First Line	:	PO BOX 250351
Second Line	:
City	:	PLANO
State	:	TX
Zip	:	75025-0351
Country	:	US
Telephone Number	:	214-390-7697
Fax Number	:	888-770-6360

Provider Business Practice Location Address
First Line	:	12200 PARK CENTRAL DR STE 135
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75251-2147
Country	:	US
Telephone Number	:	214-390-7697
Fax Number	:	888-770-6360

Authorized Official
Title or Position	:	ADMIN
Name	:	VENKAT SETHURAMAN
Credential	:
Telephone Number	:	214-390-7697

Provider Enumeration Date	:	10/17/2019
Last Update Date	:	12/10/2019

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