Healthcare Provider Details

I. General information

NPI: 1710376074
Provider Name (Legal Business Name): SPINE TEAM TEXAS, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/09/2015
Last Update Date: 01/09/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3509 SPECTRUM BLVD SUITE B
RICHARDSON TX
75082-9703
US

IV. Provider business mailing address

1545 E SOUTHLAKE BLVD SUITE 100
SOUTHLAKE TX
76092-6422
US

V. Phone/Fax

Practice location:
  • Phone: 972-772-9600
  • Fax: 972-772-9601
Mailing address:
  • Phone: 817-442-9300
  • Fax: 817-796-0763

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number
License Number State

VIII. Authorized Official

Name: MARK HOOD
Title or Position: CEO
Credential:
Phone: 817-442-9300