MEDICARE: DEFINITIVE INTERVENTIONAL SPINE CENTER

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	208VP0014X	Interventional Pain Medicine Physician	K8150	TX

General Provider Information

NPI Number	:	1891021903
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DEFINITIVE INTERVENTIONAL SPINE CENTER

Provider Business Mailing Address
First Line	:	10507 E WILDWIND CIR
Second Line	:
City	:	THE WOODLANDS
State	:	TX
Zip	:	77380-4043
Country	:	US
Telephone Number	:	713-562-7890
Fax Number	:	281-605-4566

Provider Business Practice Location Address
First Line	:	6225 FM 2920 RD
Second Line	:	SUITE 100
City	:	SPRING
State	:	TX
Zip	:	77379-3474
Country	:	US
Telephone Number	:	713-562-7890
Fax Number	:	281-605-4566

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MARK JASON FILLEY
Credential	:	M.D.
Telephone Number	:	281-543-0012

Provider Enumeration Date	:	10/23/2009
Last Update Date	:	10/23/2009

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