MEDICARE: THE SPINE AND MIGRAINE INSTITUTE 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	207L00000X	Anesthesiology Physician	231723	LA

General Provider Information

NPI Number	:	1275878506
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	THE SPINE AND MIGRAINE INSTITUTE LLC

Provider Business Mailing Address
First Line	:	PO BOX 3837
Second Line	:
City	:	CAROL STREAM
State	:	IL
Zip	:	60132-3837
Country	:	US
Telephone Number	:	214-615-5168
Fax Number	:

Provider Business Practice Location Address
First Line	:	9456 JEFFERSON HWY STE B
Second Line	:
City	:	BATON ROUGE
State	:	LA
Zip	:	70809-2883
Country	:	US
Telephone Number	:	214-615-5168
Fax Number	:

Authorized Official
Title or Position	:	DIRECTOR OF REVENUE CYCLE
Name	:	MS. MELANIE GROSS
Credential	:
Telephone Number	:	214-615-5168

Provider Enumeration Date	:	11/27/2012
Last Update Date	:	12/06/2012

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