Healthcare Provider Details

I. General information

NPI: 1629376157
Provider Name (Legal Business Name): MINIMALLY INVASIVE SPINE SPECIALIST MEDICAL CENTER, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/08/2011
Last Update Date: 03/07/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1332 W HERNDON AVE SUITE 100
FRESNO CA
93711-7118
US

IV. Provider business mailing address

PO BOX 25729
FRESNO CA
93729-5729
US

V. Phone/Fax

Practice location:
  • Phone: 559-432-1647
  • Fax: 559-432-7828
Mailing address:
  • Phone: 559-432-1647
  • Fax: 559-432-7828

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207XS0106X
TaxonomyOrthopaedic Hand Surgery Physician
License NumberC32342
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code207XS0117X
TaxonomyOrthopaedic Surgery of the Spine Physician
License NumberC32342
License Number StateCA

VIII. Authorized Official

Name: DR. STEPHEN ALLEN SMITH
Title or Position: CEO
Credential: M.D.
Phone: 559-432-1647