Healthcare Provider Details

I. General information

NPI: 1922020858
Provider Name (Legal Business Name): ADVANCED SPINE AND REHAB PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/23/2006
Last Update Date: 12/17/2025
Certification Date: 12/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4540 E BASELINE RD STE 111
MESA AZ
85206-4616
US

IV. Provider business mailing address

4540 E BASELINE RD STE 111
MESA AZ
85206-4616
US

V. Phone/Fax

Practice location:
  • Phone: 480-892-1122
  • Fax: 480-892-2243
Mailing address:
  • Phone: 480-892-1122
  • Fax: 480-892-2243

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number5447
License Number StateAZ
# 3
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number5639
License Number StateAZ

VIII. Authorized Official

Name: DR. MICHAEL DAVID CRISMON
Title or Position: PARTNER
Credential: DC
Phone: 480-892-1122