MEDICARE: SPINE SCIENCE INSTITUTE, INC, PC

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	MD 00036974	WA

General Provider Information

NPI Number	:	1891007845
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SPINE SCIENCE INSTITUTE, INC, PC

Provider Business Mailing Address
First Line	:	119 S 14TH ST
Second Line	:
City	:	MOUNT VERNON
State	:	WA
Zip	:	98274-4114
Country	:	US
Telephone Number	:	360-428-0999
Fax Number	:

Provider Business Practice Location Address
First Line	:	119 S 14TH ST
Second Line	:
City	:	MOUNT VERNON
State	:	WA
Zip	:	98274-4114
Country	:	US
Telephone Number	:	360-428-0999
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	FAROUQ A. AL-HAMDAN
Credential	:	M.D.
Telephone Number	:	713-553-3944

Provider Enumeration Date	:	07/07/2010
Last Update Date	:	07/07/2010

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