MEDICARE: PHILLY SPINE CENTER INCORPORATED

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	111N00000X	Chiropractor	DC010122	PA

General Provider Information

NPI Number	:	1366791428
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PHILLY SPINE CENTER INCORPORATED

Provider Business Mailing Address
First Line	:	11 MULBERRY LN
Second Line	:
City	:	PLYMOUTH MEETING
State	:	PA
Zip	:	19462-2438
Country	:	US
Telephone Number	:	404-428-6012
Fax Number	:

Provider Business Practice Location Address
First Line	:	3101 COTTMAN AVE
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19149-1502
Country	:	US
Telephone Number	:	215-624-6100
Fax Number	:

Authorized Official
Title or Position	:	CHIROPRACTOR
Name	:	DR. SAMUEL WINFIELD HOLLOWAY
Credential	:	D.C.
Telephone Number	:	404-428-6012

Provider Enumeration Date	:	09/05/2012
Last Update Date	:	09/05/2012

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