Healthcare Provider Details
I. General information
NPI: 1023594801
Provider Name (Legal Business Name): NEUROSPINE GROUP
Entity Type: Organization
Gender:
Sole Proprietor:
II. Dates (important events)
Enumeration Date: 07/16/2018
Last Update Date: 07/21/2022
Certification Date: 07/21/2022
Deactivation Date:
Reactivation Date:
III. Provider practice location address
74B CENTENNIAL LOOP STE 300
EUGENE OR
97401-7925
US
IV. Provider business mailing address
74B CENTENNIAL LOOP STE 300
EUGENE OR
97401-7925
US
V. Phone/Fax
- Phone: 541-686-3791
- Fax: 541-686-3795
- Phone: 541-316-6616
- Fax: 541-284-3160
VI. Provider taxonomy
Scope of Practice (Provider specialty)
| # 1 | |
| Primary Taxonomy | Y |
| Taxonomy Code | 207T00000X |
| Taxonomy | Neurological Surgery Physician |
| License Number | |
| License Number State | |
VII. Legacy identifiers
For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:
| # 1 | |
| Identifier | 1033283627 |
| Identifier Type | OTHER |
| Identifier State | OR |
| Identifier Issuer | COMMERCIAL |
| # 2 | |
| Identifier | 1033283627 |
| Identifier Type | MEDICAID |
| Identifier State | OR |
| Identifier Issuer | |
| # 3 | |
| Identifier | 1982899274 |
| Identifier Type | MEDICAID |
| Identifier State | OR |
| Identifier Issuer | |
| # 4 | |
| Identifier | 1033192760 |
| Identifier Type | OTHER |
| Identifier State | OR |
| Identifier Issuer | COMMERCIAL |
| # 5 | |
| Identifier | 1033192760 |
| Identifier Type | MEDICAID |
| Identifier State | OR |
| Identifier Issuer | |
| # 6 | |
| Identifier | 1982899274 |
| Identifier Type | OTHER |
| Identifier State | OR |
| Identifier Issuer | COMMERCIAL |
| # 7 | |
| Identifier | 1184634594 |
| Identifier Type | OTHER |
| Identifier State | OR |
| Identifier Issuer | COMMERCIAL |
| # 8 | |
| Identifier | 1184634594 |
| Identifier Type | MEDICAID |
| Identifier State | OR |
| Identifier Issuer | |
| # 9 | |
| Identifier | 1477536100 |
| Identifier Type | MEDICAID |
| Identifier State | OR |
| Identifier Issuer | |
| # 10 | |
| Identifier | 1902000599 |
| Identifier Type | MEDICAID |
| Identifier State | OR |
| Identifier Issuer | |
| # 11 | |
| Identifier | 1518639038 |
| Identifier Type | MEDICAID |
| Identifier State | OR |
| Identifier Issuer | |
| # 12 | |
| Identifier | 1831475573 |
| Identifier Type | MEDICAID |
| Identifier State | OR |
| Identifier Issuer | |
| # 13 | |
| Identifier | 1902000599 |
| Identifier Type | OTHER |
| Identifier State | OR |
| Identifier Issuer | COMMERCIAL |
| # 14 | |
| Identifier | 1477536100 |
| Identifier Type | OTHER |
| Identifier State | OR |
| Identifier Issuer | COMMERCIAL |
| # 15 | |
| Identifier | 1831475573 |
| Identifier Type | OTHER |
| Identifier State | OR |
| Identifier Issuer | COMMERCIAL |
VIII. Authorized Official
Name:
NICOLE
LEISHMAN
Title or Position: CREDENTIALING SPECIALIST
Credential:
Phone: 541-316-6616