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General NPI Number Information
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NPI Number | 1639406440
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Entity Type | Organization
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Legal Business Name | SPINE CONSULTANTS, LLC
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Dates
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Enumeration Date | 11/16/2009
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Last Update Date | 12/20/2023
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Provider Practice Location Address
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Address Line | 2514 VILLAGE GREEN PL
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City | CHAMPAIGN
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State | IL
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Zip | 61822-7675
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Country | US
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Telephone | 773-321-2800
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Fax | 773-321-2801
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Provider Business Mailing Address
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Address Line | 2514 VILLAGE GREEN PL
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City | CHAMPAIGN
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State | IL
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Zip | 61822-7675
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Country | US
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Telephone | 773-321-2800
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Fax | 773-321-2801
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Authorized Official
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Title or Position | PRACTICE ADMINISTRATOR
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Name | BAILEY BLYTHIN
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Credential |
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Telephone | 773-321-2800
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207X00000X
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Taxonomy Name | Orthopaedic Surgery Physician
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License Number | 036094206
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License Number State | IL
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