Healthcare Provider Details

I. General information

NPI: 1902479132
Provider Name (Legal Business Name): STRONG SPINE INSTITUTE, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/24/2021
Last Update Date: 07/26/2021
Certification Date: 07/26/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

64 SHELDON LN
HIGHLAND PARK IL
60035-5132
US

IV. Provider business mailing address

64 SHELDON LN
HIGHLAND PARK IL
60035-5132
US

V. Phone/Fax

Practice location:
  • Phone: 773-682-7661
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: DMITRY NOVOSELETSKY
Title or Position: MANAGER
Credential: MD
Phone: 773-682-7661