Healthcare Provider Details

I. General information

NPI: 1093236283
Provider Name (Legal Business Name): SPINE MANAGEMENT GROUP, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/28/2017
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4600 S CLAIBORNE AVE STE 100
NEW ORLEANS LA
70125-5010
US

IV. Provider business mailing address

4600 S CLAIBORNE AVE STE 100
NEW ORLEANS LA
70125-5010
US

V. Phone/Fax

Practice location:
  • Phone: 504-899-2225
  • Fax: 504-899-2280
Mailing address:
  • Phone: 504-899-2225
  • Fax: 504-899-2280

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081P2900X
TaxonomyPain Medicine (Physical Medicine & Rehabilitation) Physician
License Number201144
License Number StateLA

VIII. Authorized Official

Name: MRS. ROSE KLEIN
Title or Position: OFFICE MANAGER
Credential:
Phone: 504-394-0001