=====================================================
General NPI Number Information
=====================================================
NPI Number | 1386830420
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | COMPREHENSIVE SPINE CARE AND ORTHOPEDIC SURGERY, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/22/2007
-----------------------------------------------------
Last Update Date | 12/28/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 65 PENNSYLVANIA AVE
-----------------------------------------------------
City | BINGHAMTON
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 13903-1608
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 607-773-2225
-----------------------------------------------------
Fax | 607-754-1477
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 65 PENNSYLVANIA AVE
-----------------------------------------------------
City | BINGHAMTON
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 13903-1608
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 607-773-2225
-----------------------------------------------------
Fax | 607-754-1477
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. ERIC A SEYBOLD
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 607-773-2225
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | X009073-1
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 208VP0014X
-----------------------------------------------------
Taxonomy Name | Interventional Pain Medicine Physician
-----------------------------------------------------
License Number | 230204-1
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 207XS0117X
-----------------------------------------------------
Taxonomy Name | Orthopaedic Surgery of the Spine Physician
-----------------------------------------------------
License Number | 209065-1
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------