=====================================================
General NPI Number Information
=====================================================
NPI Number | 1831445030
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MINIMALLY INVASIVE BRAIN AND SPINE, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/25/2012
-----------------------------------------------------
Last Update Date | 08/21/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3400 BISSONNET ST SUITE 220
-----------------------------------------------------
City | HOUSTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77005-2155
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 281-652-5500
-----------------------------------------------------
Fax | 713-664-4488
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 272008
-----------------------------------------------------
City | HOUSTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77277-2008
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 281-652-5500
-----------------------------------------------------
Fax | 713-664-4488
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. ANTHONY VITO MAIORIELLO
-----------------------------------------------------
Credential | MD, MS, FAANS, FACS
-----------------------------------------------------
Telephone | 281-652-5500
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207T00000X
-----------------------------------------------------
Taxonomy Name | Neurological Surgery Physician
-----------------------------------------------------
License Number | L8424
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------