=====================================================
General NPI Number Information
=====================================================
NPI Number | 1972789204
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SPINE INTERVENTION CLINIC, P.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/16/2008
-----------------------------------------------------
Last Update Date | 09/02/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 512 7TH STREET
-----------------------------------------------------
City | OREGON CITY
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97045-1853
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 503-742-0632
-----------------------------------------------------
Fax | 503-387-3106
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 1836
-----------------------------------------------------
City | OREGON CITY
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97045-0836
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 503-742-0632
-----------------------------------------------------
Fax | 503-387-3106
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MICHAEL BESPALY
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 503-742-0632
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207LP2900X
-----------------------------------------------------
Taxonomy Name | Pain Medicine (Anesthesiology) Physician
-----------------------------------------------------
License Number | MD20637
-----------------------------------------------------
License Number State | OR
-----------------------------------------------------