=====================================================
General NPI Number Information
=====================================================
NPI Number | 1245306489
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SPINAL CARE PAIN ASSOCIATES, P.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/28/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2410 S BROAD ST 3RD FLOOR
-----------------------------------------------------
City | PHILADELPHIA
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19145-4418
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 215-462-6600
-----------------------------------------------------
Fax | 215-462-2650
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2410 S BROAD ST 3RD FLOOR
-----------------------------------------------------
City | PHILADELPHIA
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19145-4418
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 215-462-6600
-----------------------------------------------------
Fax | 215-462-2650
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEDICAL DIRECTOR
-----------------------------------------------------
Name | DR. GLENN MILLER
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 215-462-6600
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208VP0014X
-----------------------------------------------------
Taxonomy Name | Interventional Pain Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------