Healthcare Provider Details

I. General information

NPI: 1639317332
Provider Name (Legal Business Name): ADVANCED SPINE AND PAIN CENTER, P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/03/2009
Last Update Date: 03/01/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 MEDICAL DR
BENSON NC
27504-1177
US

IV. Provider business mailing address

PO BOX 839
BENSON NC
27504
US

V. Phone/Fax

Practice location:
  • Phone: 919-894-1740
  • Fax: 919-894-2701
Mailing address:
  • Phone: 919-894-1740
  • Fax: 919-894-2701

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 Number
License Number State

VIII. Authorized Official

Name: RACHID IDRISSI
Title or Position: PRESIDENT
Credential: MD
Phone: 919-894-1740