Healthcare Provider Details

I. General information

NPI: 1508165671
Provider Name (Legal Business Name): ADVANCED INTERVENTIONAL SPINE AND SURGERY PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/15/2011
Last Update Date: 03/15/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6382 E MILLBROOK RD
SHEPHERD MI
48883-9327
US

IV. Provider business mailing address

6382 E MILLBROOK RD
SHEPHERD MI
48883-9327
US

V. Phone/Fax

Practice location:
  • Phone: 989-400-6932
  • Fax:
Mailing address:
  • Phone: 989-400-6932
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number4301092952
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number4301092952
License Number StateMI
# 3
Primary TaxonomyN
Taxonomy Code261QP3300X
TaxonomyPain Clinic/Center
License Number4301092952
License Number StateMI

VIII. Authorized Official

Name: MISS CINDY ESCH
Title or Position: PRESIDENT
Credential:
Phone: 989-400-6932