MEDICARE: THE SPINE TREATMENT CENTER,LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QA1903X	Ambulatory Surgical Clinic/Center	APPLIED	GA

General Provider Information

NPI Number	:	1225064363
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	THE SPINE TREATMENT CENTER,LLC

Provider Business Mailing Address
First Line	:	1111 GLYNCO PKWY
Second Line	:	3RD FLOOR
City	:	BRUNSWICK
State	:	GA
Zip	:	31525-7921
Country	:	US
Telephone Number	:	912-262-6552
Fax Number	:	912-262-0112

Provider Business Practice Location Address
First Line	:	1111 GLYNCO PKWY
Second Line	:	3RD FLOOR
City	:	BRUNSWICK
State	:	GA
Zip	:	31525-7921
Country	:	US
Telephone Number	:	912-262-6552
Fax Number	:	912-262-0112

Authorized Official
Title or Position	:	MANAGING MEMBER
Name	:	DR. MARK A. GOLD
Credential	:	M.D.
Telephone Number	:	912-262-6552

Provider Enumeration Date	:	06/23/2006
Last Update Date	:	08/22/2020

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