Healthcare Provider Details

I. General information

NPI: 1043517899
Provider Name (Legal Business Name): PENNSYLVANIA SPINE & HEADACHE CENTER, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/14/2011
Last Update Date: 04/03/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3 N 2ND ST STE 3
PHILADELPHIA PA
19106-2208
US

IV. Provider business mailing address

760 W LINCOLN HWY
EXTON PA
19341-2547
US

V. Phone/Fax

Practice location:
  • Phone: 215-776-6404
  • Fax:
Mailing address:
  • Phone: 610-716-1879
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code273Y00000X
TaxonomyRehabilitation Hospital Unit
License NumberMD041591E
License Number StatePA

VIII. Authorized Official

Name: BRUCE LEVIN
Title or Position: OWNER
Credential:
Phone: 215-776-6404