MEDICARE: PIEDMONT SPINE SPECIALISTS, PA

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	208VP0000X	Pain Medicine Physician		NC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	017P7	OTHER	NC	BLUE CROSS/BLUE SHIELD

General Provider Information

NPI Number	:	1720028558
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PIEDMONT SPINE SPECIALISTS, PA

Provider Business Mailing Address
First Line	:	PO BOX 16934
Second Line	:
City	:	CHAPEL HILL
State	:	NC
Zip	:	27516-6934
Country	:	US
Telephone Number	:	919-442-2407
Fax Number	:	919-967-6647

Provider Business Practice Location Address
First Line	:	3480 WAKE FOREST RD
Second Line	:	SUITE 208
City	:	RALEIGH
State	:	NC
Zip	:	27609-7376
Country	:	US
Telephone Number	:	919-781-4541
Fax Number	:	919-781-4812

Authorized Official
Title or Position	:	PRESIDENT
Name	:	JOHN GREGORY BENTLEY
Credential	:	MD
Telephone Number	:	919-781-4541

Provider Enumeration Date	:	06/08/2006
Last Update Date	:	12/21/2007

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