Healthcare Provider Details

I. General information

NPI: 1548253933
Provider Name (Legal Business Name): ADVANCED SPINE ASSOCIATES PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/31/2005
Last Update Date: 12/17/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8232 HIGHWAY 65 NE
SPRING LAKE PARK MN
55432-2095
US

IV. Provider business mailing address

8232 HIGHWAY 65 NE
SPRING LAKE PARK MN
55432-2095
US

V. Phone/Fax

Practice location:
  • Phone: 763-577-1877
  • Fax: 763-577-1887
Mailing address:
  • Phone: 763-577-1877
  • Fax: 763-577-1887

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207XS0117X
TaxonomyOrthopaedic Surgery of the Spine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2081P2900X
TaxonomyPain Medicine (Physical Medicine & Rehabilitation) Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State

VIII. Authorized Official

Name: DR. GARRY M BANKS
Title or Position: M.D.
Credential: M.D.
Phone: 763-577-1877