Healthcare Provider Details

I. General information

NPI: 1023079183
Provider Name (Legal Business Name): HAIDER SPINE CENTER MEDICAL GROUP INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/29/2006
Last Update Date: 12/09/2025
Certification Date: 12/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6276 RIVER CREST DR
RIVERSIDE CA
92507-0754
US

IV. Provider business mailing address

6276 RIVER CREST DR STE A
RIVERSIDE CA
92507-0754
US

V. Phone/Fax

Practice location:
  • Phone: 952-141-3020
  • Fax: 951-653-5161
Mailing address:
  • Phone: 951-413-0200
  • Fax: 951-653-5161

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207T00000X
TaxonomyNeurological Surgery Physician
License Number20A8197
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code207XS0117X
TaxonomyOrthopaedic Surgery of the Spine Physician
License NumberG61537
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code207XS0117X
TaxonomyOrthopaedic Surgery of the Spine Physician
License NumberA107599
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code207XS0117X
TaxonomyOrthopaedic Surgery of the Spine Physician
License NumberG81353
License Number StateCA
# 5
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberPA18101
License Number StateCA

VIII. Authorized Official

Name: THOMAS T HAIDER
Title or Position: PRESIDENT
Credential: M.D.
Phone: 951-413-0964