Healthcare Provider Details

I. General information

NPI: 1336181163
Provider Name (Legal Business Name): INSTITUTE FOR SPINE INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/13/2006
Last Update Date: 11/03/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7551 FREDLE DR
CONCORD TWP OH
44077-9406
US

IV. Provider business mailing address

7551 FREDLE DR
CONCORD TWP OH
44077-9406
US

V. Phone/Fax

Practice location:
  • Phone: 440-357-1502
  • Fax: 440-357-1905
Mailing address:
  • Phone: 440-357-1502
  • Fax: 440-357-1905

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207XS0117X
TaxonomyOrthopaedic Surgery of the Spine Physician
License Number35056000
License Number StateOH

VIII. Authorized Official

Name: MACHELLE GIORDON
Title or Position: CREDENTIALING SPECIALIST
Credential:
Phone: 330-723-2111