Healthcare Provider Details

I. General information

NPI: 1538717483
Provider Name (Legal Business Name): SPINE HYDER PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/03/2019
Last Update Date: 05/07/2021
Certification Date: 05/07/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11055 BROADWAY STE A
CROWN POINT IN
46307-7300
US

IV. Provider business mailing address

11055 BROADWAY STE A
CROWN POINT IN
46307-7300
US

V. Phone/Fax

Practice location:
  • Phone: 219-797-7463
  • Fax: 219-310-8951
Mailing address:
  • Phone: 219-797-7463
  • Fax: 219-310-8951

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QR0200X
TaxonomyRadiology Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code207XS0117X
TaxonomyOrthopaedic Surgery of the Spine Physician
License Number
License Number State

VIII. Authorized Official

Name: ZESHAN M HYDER
Title or Position: AUTHHORIZED OFFICIAL
Credential: DO
Phone: 219-797-7463