Healthcare Provider Details

I. General information

NPI: 1255799375
Provider Name (Legal Business Name): ADVANCED SPINE AND PAIN CENTER, P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/03/2016
Last Update Date: 05/17/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 MEDICAL DR
BENSON NC
27504-1177
US

IV. Provider business mailing address

166 SPRINGBROOK AVE SUITE 105
CLAYTON NC
27520-8520
US

V. Phone/Fax

Practice location:
  • Phone: 919-894-1740
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081P2900X
TaxonomyPain Medicine (Physical Medicine & Rehabilitation) Physician
License Number2007-00587
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License Number2007-00587
License Number StateNC

VIII. Authorized Official

Name: RACHID IDRISSI
Title or Position: MEMBER OWNER
Credential:
Phone: 919-359-8643